COMMERCIAL VEHICLE INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them. A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen Policy is available on request.

DATE INSURANCE IS TO BEGIN (which cannot be before the proposal is accepted by the Insurers)

EXPIRY DATE

Name of Proposer:

NIB#:

Postal Address:

E-mail:

Telephone:

Office:

Mobile:

Fax:

Proposer's Business / Use of Vehicles:

Address at which vehicles are kept:

Currency required (B$ / US$):

VEHICLE(S) TO BE INSURED

Serial or Chassis Number

Year

Make

Model

Type of Body

Engine Capacity

Seating Capacity

Date of Purchase

Price paid by you

Insured's Estimate of Present Value

Serial or Chassis Number

Year

Make

Model

Type of Body

Engine Capacity

Seating Capacity

Date of Purchase

Price paid by you

Insured's Estimate of Present Value

Serial or Chassis Number

Year

Make

Model

Type of Body

Engine Capacity

Seating Capacity

Date of Purchase

Price paid by you

Insured's Estimate of Present Value

GOODS VEHICLES

Do you undertake the cartage of goods for other persons for hire or reward, or do you make any charge whatsoever to other persons for the use of any vehicle?

YES

b) Maker's carrying capacity:

Is any vehicle hired out for the purpose of being driven by the hirer?

YES

Has any vehicle been altered or adapted to carry a load heavier than that stated in the Maker's published specification?

YES

If 'YES', give details:

e) General nature of goods carried by each vehicle or trailer:

Will any vehicle or trailer carry goods of explosive, inflammable or dangerous nature?

YES

If 'YES', give details:

TRAILERS

3. a) Will a trailer be drawn?

YES

If 'YES', state Make and Maker's No.:

Estimate of present value of trailer:

Maximum carrying capacity:

If more than one trailer is drawn at a time, give details:

OWNERSHIP OF VEHICLES

a) Are you the owner of the vehicles and are they registered in your name?

YES

If 'NO', state the name and address of:

i) the owner:

ii)

the person in whose name the vehicles are registered:

Does any finance company have an interest in the vehicles?

YES

If 'YES', state the name and address of the finance company:

DRIVERS

Have you, or any of the persons who will drive:

Suffered from diabetes, epilepsy, heart condition, defective vision or hearing, or any other physical or mental disability, infirmity or disease?

YES

If 'YES', give details:

Been convicted during the past 5 years of an offence in connection with a motor vehicle, or are any prosecutions pending?

YES

If 'YES', give details:

Give the following particulars for each person to be named as an Authorized Driver on The Policy:

Full Name

Date of Birth Day-Month-Year

Period of driving experience with the type of vehicle proposed for insurance

Details of any vehicle accidents during the past 4 years

Full Name

Date of Birth Day-Month-Year

Period of driving experience with the type of vehicle proposed for insurance

Details of any vehicle accidents during the past 4 years

Full Name

Date of Birth Day-Month-Year

Period of driving experience with the type of vehicle proposed for insurance

Details of any vehicle accidents during the past 4 years

INSURANCE REQUIRED

11. Level of cover required:

COMPREHENSIVE

THIRD PARTY FIRE & THEFT

THIRD PARTY ONLY

12.

Do you wish to extend the policy to cover your legal liability to passengers (other than employees)?

YES

Note: This cover is compulsory for vehicles carrying passengers for hire or reward. This cover will only apply to passengers carried in properly constructed seats.

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT 2003

The information supplied when arranging this insurance policy may be shared for insurance purposes and services with other companies and organisations. For full details please refer to the Data Protection Act Statement available from Insurance Management (Bahamas) Ltd.

DECLARATION

I/We declare that the above statements made by me/us or written in answer to the questions on this form on my/our behalf by someone else are to the best of my/our knowledge and belief true and complete, and no material fact has been misrepresented, misstated or withheld. I/We agree that this proposalshall form the basis of the contract between me/us and the Insurers and will be deemed as incorporated in the Policy to be issued.

I/We understand that in respect of comprehensive cover, in the event of the total loss of the motor vehicle, the Insurers liability shall be limited to the reasonable market value of the motor vehicle at the time of the loss but not exceeding the Insured's Estimate of Value as stated overleaf.

I/We agree that an electronically transmitted signature affixed to this document shall have the force and effect of an original signature.

COMMERCIAL VEHICLE INSURANCE PROPOSAL FORM

VEHICLE(S) TO BE INSURED

PASSENGER VEHICLES

GOODS VEHICLES

TRAILERS

OWNERSHIP OF VEHICLES

DRIVERS

PREVIOUS INSURANCE

INSURANCE REQUIRED

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT 2003

DECLARATION

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