Form name:
<div class="rounderCornerMiddle"> <div id="wrapper"> <div class="headerText"> PROPOSAL FORM FOR PRIVATE CAR INSURANCE </div> <br /> <div> <strong>No risk attaches until the proposal has been accepted by the company and premium is paid or agreed to be paid</strong> </div> <br /> <fieldset> <legend>Your Details </legend> <div class="itemField"> <div class="listDiv2"> Full name: </div> <div class="listDiv"> <input type="text" name="txbFullName" /></div> </div> <div class="itemField"> <div class="listDiv2"> Your address: </div> <div class="listDiv"> <textarea rows="4" cols="22" name="txbAddress"></textarea></div> </div> <div class="itemField"> <div class="listDiv2"> Occupation: </div> <div class="listDiv"> <input type="text" name="txbOccupation" /></div> </div> <div class="itemField"> <div class="listDiv2"> Address: </div> <div class="listDiv"> <textarea rows="4" cols="22" name="txbPostalAddress"></textarea></div> </div> <div class="itemField"> <strong>Telephone: </strong> </div> <div class="itemField"> <div class="listDiv2"> Work</div> <div class="listDiv"> <input type="text" name="txbWork" /></div> </div> <div class="itemField"> <div class="listDiv2"> Home</div> <div class="listDiv"> <input type="text" name="txbHome" /></div> </div> <div class="itemField"> <div class="listDiv2"> Mobile</div> <div class="listDiv"> <input type="text" name="txbMobile" /></div> </div> <div class="itemField"> <div class="listDiv2"> Email</div> <div class="listDiv"> <input type="text" name="txbEmail" /></div> </div> <div class="itemField"> <div class="listDiv2"> Interested Bank/Finance Company: </div> <div class="listDiv"> <input type="text" name="txbBank/Finance" /></div> </div> </fieldset> <fieldset> <legend>YOUR DUTY OF DISCLOSURE </legend> <div class="itemField"> You must tell us everything you know (or could be reasonably expected to know) that a prudent insurer would want to take into account in deciding: <br /> <ul> • Whether to accept your proposal, and <br /> • If so, on what terms. </ul> Examples of what you must tell us include: <ul> • Anything that increases the risk of a claim<br /> • Any criminal offending or convictions<br /> • Any previous insurance claims<br /> • Any refusal by another insurer to insure you on standard terms, or continue to insure you on standard terms </ul> You must also tell us this every time this policy renews, and when you make any changes to it. <br />If you fail to do this, we may avoid the policy back to when it started as if you were never insured at all. <br />When in doubt, disclose. We treat all information confidentially. </div> </fieldset> <fieldset> <legend>YOUR PRIVACY </legend> <div class="itemField"> We collect and receive your personal information in this proposal to decide whether to insure you. We hold it in our records. <br /> <br /> You have rights to access it, and correct it under the Privacy Act 1993. You must supply your personal information to us if it comes within your duty of disclosure (see Your Duty of Disclosure above). <br /> <br /> If you fail to do so, we may decline your proposal or avoid your insurance retrospectively. We obtain your authority below to transfer some or all of it to other members of the insurance industry, financially interested parties noted on your policy and Insurance Claims Register Limited. </div> </fieldset> <fieldset> <legend>YOUR PREVIOUS HISTORY </legend> <div class="checkboxItemField"> <label> Has any insurer ever refused to insure you on standard terms, or refused to renew your insurance on standard terms? </label> <input type="radio" value="Yes" name="rbtnInsurer" /> <input type="radio" value="No" name="rbtnInsurer" /> </div> <div class="checkboxItemField"> <label> Has any insurer ever refused to pay your insurance claim? </label> <input type="radio" value="Yes" name="rbtnInsuranceClaim" /> <input type="radio" value="No" name="rbtnInsuranceClaim" /> </div> <div class="checkboxItemField"> <label> Have you made any insurance claim in the last five years? (If yes, please explain in detail)</label> <input type="radio" value="Yes" name="rbtnPay" /> <input type="radio" value="No" name="rbtnPay" /> </div> <div class="itemField"> <div class="listDiv2"> If yes, please explain in detail: </div> <div class="listDiv"> <textarea rows="5" cols="30" name="txbExplanation"></textarea></div> </div> <div class="checkboxItemField"> <label> Do you know of any circumstances that could lead to a claim under any of our policies in the future? </label> <input type="radio" value="Yes" name="rbtncirCumstances" /> <input type="radio" value="No" name="rbtncirCumstances" /> </div> <div class="checkboxItemField"> <label> Do you have any criminal convictions (including traffic offences, but not parking offences), or are you currently facing a prosecution? If yes, please list each offence or prosecution, and each sentence you received. </label> <input type="radio" value="Yes" name="rbtnCriminal" /> <input type="radio" value="No" name="rbtnCriminal" /> <br /> <br /> <textarea rows="5" cols="30" name="txbCriminal"></textarea> </div> <div class="checkboxItemField"> <label> What type of Cover do you require</label> <input type="radio" value="Full Cover” name="rbtnCover" /> <input type="radio" value="Third Party Fire & Theft " name="rbtnCover" /> <input type="radio" value="Third Party Only” name="rbtnCover" /> </div> <div class="itemField"> <div class="listDiv2"> Please list details of car(s)/vehicle, caravan/motorcycle/trailer/other.</div> </div> <div class="itemField"> <table> <tbody> <tr> <td> Year </td> <td> Make </td> <td> Model </td> <td> Engine Size<br /> and type </td> <td> Registration Number </td> <td> Market Value </td> </tr> <tr> <td> <input type="text" name="txbYear1" /> </td> <td> <input type="text" name="txbMake1" /> </td> <td> <input type="text" name="txbModel1" /> </td> <td> <input type="text" name="txbEngineSize1" /> </td> <td> <input type="text" name="txbRegistration1" /> </td> <td> <input type="text" name="txbMarketValue1" /> </td> </tr> <tr> <td> <input type="text" name="txbYear2" /> </td> <td> <input type="text" name="txbMake2" /> </td> <td> <input type="text" name="txbModel2" /> </td> <td> <input type="text" name="txbEngineSize2" /> </td> <td> <input type="text" name="txbRegistration2" /> </td> <td> <input type="text" name="txbMarketValue2" /> </td> </tr> <tr> <td> <input type="text" name="txbYear3" /> </td> <td> <input type="text" name="txbMake3" /> </td> <td> <input type="text" name="txbModel3" /> </td> <td> <input type="text" name="txbEngineSize3" /> </td> <td> <input type="text" name="txbRegistration3" /> </td> <td> <input type="text" name="txbMarketValue3" /> </td> </tr> </tbody> </table> </div> <div class="itemField"> Has any car been modified from the manufacturer's standard specifications? If so, please provide full details below. (Please list car accessories in excess of $1000.) </div> <div class="itemField"> <table> <tbody> <tr> <td> Who will drive your car? </td> <td> Name </td> <td> Sex </td> <td> DOB </td> <td> Type of Driving License </td> </tr> <tr> <td> Main driver </td> <td> <input type="text" name="txbDriverName1" /> </td> <td> <input type="text" name="txbSex1" /> </td> <td> <input type="text" name="txbDateOfBirth1" /> </td> <td> <input type="text" name="txbDrivingLicence1" /> </td> </tr> <tr> <td> 1st additional driver </td> <td> <input type="text" name="txbDriverName2" /> </td> <td> <input type="text" name="txbSex2" /> </td> <td> <input type="text" name="txbDateOfBirth2" /> </td> <td> <input type="text" name="txbDrivingLicence2" /> </td> </tr> <tr> <td> 2nd additional driver </td> <td> <input type="text" name="txbDriverName3" /> </td> <td> <input type="text" name="txbSex3" /> </td> <td> <input type="text" name="txbDateOfBirth3" /> </td> <td> <input type="text" name="txbDrivingLicence3" /> </td> </tr> </tbody> </table> </div> <div class="checkboxItemField"> <label> Do you want to exclude drivers under 25 for a premium discount? </label> <input type="radio" value="Yes" name="rbtnExclude" /> <input type="radio" value="No" name="rbtnExclude" /> </div> <div class="checkboxItemField"> <label> Does the main driver own the vehicle? </label> <input type="radio" value="Yes" name="rbtnMain" /> <input type="radio" value="No" name="rbtnMain" /> </div> </fieldset> <fieldset> <legend>YOUR DECLARATION </legend> <div class="itemField"> I declare that I:1 <ul> <ol> 1 Have answered all questions truthfully. </ol> <ol> 2 Have, in addition, disclosed all material facts to New India (please see Your Duty of Disclosure above) </ol> <ol> 3 Agree to the policy terms and conditions. </ol> <ol> 4 Authorize: </ol> <ol> <ul> <ol> 4.1 New India to advise me of its other services from time to time </ol> <ol> 4.2 The disclosure of my personal information held by New India to: </ol> <ol> <ul> <ol> 4.2.1 Other members of the insurance industry, and </ol> <ol> 4.2.2 Financially interested parties noted on the policy, and </ol> <ol> 4.2.3 Insurance Claims Register Limited. </ol> </ul> </ol> <ol> 4.3 The disclosure of my personal information held by: </ol> <ol> <ul> <ol> 4.3.1 Other members of the insurance industry, and </ol> <ol> 4.3.2 Insurance Claims Register Limited to New India for the purpose of considering this proposal and administering the policy </ol> </ul> </ol> </ul> </ol> <ol> 5 Am authorized by everyone else to be insured under the policy to complete this proposal on their behalf, and they give the same declarations above. Signature of Proposer </ol> </ul> </div> </fieldset> </div> </div>