Diyadio WebForms :: Webform Designer

Form name:

<div class="rounderCornerMiddle">
    <div class="rounderCornerMiddle">
        <div class="wrapper">
            <div class="headerText">
                PROPOSAL FOR COMMERCIAL MOTOR VEHICLE
                <p>
                    No risk attaches until the proposal has been accepted by the company and premium
                    is paid or agreed to be paid
                </p>
            </div>
            <fieldset>
                <legend>Your Details </legend>
                <div class="itemField">
                    <div class="listDiv">
                        Business name:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbBussinessName" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Business’s Physical Address:
                    </div>
                    <div class="listDiv">
                        <textarea name="txbBussinessPhysicalAddress" rows="5" cols="22"></textarea>
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Type of Business:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbBussinessType" />
                    </div>
                </div>
                <div class="itemField">
                    <span class="blueBolderText">Contact details: </span>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Postal Address:
                    </div>
                    <div class="listDiv">
                        <textarea name="txbPostalAddress" cols="22" rows="5"></textarea>
                    </div>
                </div>
                <div class="itemField">
                    <span class="blueBolderText">Telephone</span>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Work:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbWork" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Home:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbHome" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Mobile:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbMobile" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Email:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbEmail" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Interested Bank /Finance Company
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbInterestedBank" />
                    </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: whether to accept
                    your proposal, and if so, on what terms.
                    <br />
                    Examples of what you must tell us include:
                    <br />
                    <ul>
                        <li>Anything that increases the risk of a claim</li>
                        <li>Any criminal offending or convictions</li>
                        <li>Any previous insurance claims</li>
                        <li>Any refusal by another insurer to insure you on standard terms, or continue to insure
                            you on standard terms. </li>
                    </ul>
                    <br />
                    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. You have rights to access it, and correct it under the
                    Privacy Act 1993.
                    <br />
                    <br />
                    You must supply your personal information to us if it comes within your duty of
                    disclosure (see Your Duty of Disclosure above). If you fail to do so, we may decline
                    your proposal or avoid your insurance retrospectively.
                    <br />
                    <br />
                    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="itemField">
                    The following questions must be answered in relation to the business, and in relation
                    to every director and manager of the business
                </div>
                <div class="itemField">
                    <label>
                        Has any insurer ever refused to insure you on standard terms, or refused to renew
                        your insurance on standard terms?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnInsurer" value="Yes" />
                        <input type="radio" name="rbtnInsurer" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Has any insurer ever refused to pay your insurance claim?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnInsurenceClaim" value="Yes" />
                        <input type="radio" name="rbtnInsurenceClaim" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Have you made any insurance claim in the last five years?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnInsurenceinFiveYears" value="Yes" />
                        <input type="radio" name="rbtnInsurenceinFiveYears" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Do you know of any circumstances that could lead to a claim under any of our policies
                        in the future?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnCircumstances" value="Yes" />
                        <input type="radio" name="rbtnCircumstances" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <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 your business has received.
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnCriminalConvictions" value="Yes" />
                        <input type="radio" name="rbtnCriminalConvictions" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        If you have answered yes to any of the above questions, please write full details
                        below
                    </div>
                    <div class="listDiv">
                        <textarea name="txbAnswers" rows="5" cols="55"></textarea>
                    </div>
                </div>
            </fieldset>
            <fieldset>
                <legend>MOTOR VEHICLE DETAILS </legend>
                <div class="itemField">
                    <label>
                        What type of cover do you require?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnCover" value="Full cover" />
                        <input type="radio" name="rbtnCover" value="Third party Fire and Theft" />
                        <input type="radio" name="rbtnCover" value="Third party only" />
                    </div>
                </div>
                <div class="itemField">
                    <strong>List the details of car(s)/truck, trailer/other</strong>
                </div>
                <div class="itemField">
                    <table width="600px" cellpadding="0" cellspacing="2" border="1px">
                        <tr class="blueBolderText">
                            <th class="style1">
                                Year
                            </th>
                            <th class="style2">
                                Make
                            </th>
                            <th>
                                Chassis Number
                            </th>
                            <th>
                                Engine size and number
                            </th>
                            <th>
                                Registration Number & class of license required to operate
                            </th>
                            <th class="style3">
                                Market Value
                            </th>
                        </tr>
                        <tr>
                            <td class="style1">
                                &nbsp;
                                <input type="text" name="txbYear1" />
                            </td>
                            <td class="style2">
                                &nbsp;
                                <input type="text" name="txbMake1" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClassicNumber1" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbEngineSize1" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbRegistraition1" />
                            </td>
                            <td class="style3">
                                &nbsp;
                                <input type="text" name="txbMarket1" />
                            </td>
                        </tr>
                        <tr>
                            <td class="style1">
                                &nbsp;
                                <input type="text" name="txbYear2" />
                            </td>
                            <td class="style2">
                                &nbsp;
                                <input type="text" name="txbMake2" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClassicNumber2" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbEngineSize2" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbRegistraition2" />
                            </td>
                            <td class="style3">
                                &nbsp;
                                <input type="text" name="txbMarket2" />
                            </td>
                        </tr>
                        <tr>
                            <td class="style1">
                                &nbsp;
                                <input type="text" name="txbYear3" />
                            </td>
                            <td class="style2">
                                &nbsp;
                                <input type="text" name="txbMake3" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClassicNumber3" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbEngineSize3" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbRegistraition3" />
                            </td>
                            <td class="style3">
                                &nbsp;
                                <input type="text" name="txbMarket3" />
                            </td>
                        </tr>
                        <tr>
                            <td class="style1">
                                &nbsp;
                                <input type="text" name="txbYear4" />
                            </td>
                            <td class="style2">
                                &nbsp;
                                <input type="text" name="txbMake4" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClassicNumber4" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbEngineSize4" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbRegistraition4" />
                            </td>
                            <td class="style3">
                                &nbsp;
                                <input type="text" name="txbMarket4" />
                            </td>
                        </tr>
                        <tr>
                            <td class="style1">
                                &nbsp;
                                <input type="text" name="txbYear5" />
                            </td>
                            <td class="style2">
                                &nbsp;
                                <input type="text" name="txbMake5" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClassicNumber5" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbEngineSize5" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbRegistraition5" />
                            </td>
                            <td class="style3">
                                &nbsp;
                                <input type="text" name="txbMarket5" />
                            </td>
                        </tr>
                    </table>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Has any vehicle been modified from the manufacturer standard specifications? If
                        so, please provide full details below
                    </div>
                    <div class="listDiv">
                        <textarea name="txbFullDetails" rows="6" cols="65"></textarea>
                    </div>
                </div>
                <div class="itemField">
                    <span class="blueBolderText">Driver Details</span>
                </div>
                <div class="itemField">
                    Please complete in relation to all drivers
                </div>
                <div class="itemField">
                    <table width="600px" cellpadding="0" cellspacing="2" border="1px">
                        <tr class="blueBolderText">
                            <th class="style4">
                                Name
                            </th>
                            <th class="style5">
                                Date of birth
                            </th>
                            <th class="style6">
                                Type of License
                            </th>
                            <th>
                                Years had license for class of vehicle
                            </th>
                            <th>
                                Percentage use of the vehicle
                            </th>
                        </tr>
                        <tr>
                            <td class="style4">
                                &nbsp;
                                <input type="text" name="txbName1" />
                            </td>
                            <td class="style5">
                                &nbsp;
                                <input type="text" name="txbDateOfBirth1" />
                            </td>
                            <td class="style6">
                                &nbsp;
                                <input type="text" name="txbLicence1" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClass1" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbPercentage1" />
                            </td>
                        </tr>
                        <tr>
                            <td class="style4">
                                &nbsp;
                                <input type="text" name="txbName2" />
                            </td>
                            <td class="style5">
                                &nbsp;
                                <input type="text" name="txbDateOfBirth2" />
                            </td>
                            <td class="style6">
                                &nbsp;
                                <input type="text" name="txbLicence2" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClass2" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbPercentage2" />
                            </td>
                        </tr>
                        <tr>
                            <td class="style4">
                                &nbsp;
                                <input type="text" name="txbName3" />
                            </td>
                            <td class="style5">
                                &nbsp;
                                <input type="text" name="txbDateOfBirth3" />
                            </td>
                            <td class="style6">
                                &nbsp;
                                <input type="text" name="txbLicence3" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbClass3" />
                            </td>
                            <td>
                                &nbsp;
                                <input type="text" name="txbPercentage3" />
                            </td>
                        </tr>
                    </table>
                </div>
                <div class="itemField">
                    Please give details of any accidents or motor vehicle claims (whether your fault
                    or not) during the last 3 years in connection with a motor vehicle owned or operated
                    by you, or any person who will drive the vehicles:
                </div>
                <div>
                    <div class="itemField">
                        <table cellpadding="0" cellspacing="2" border="1px" style="width: 632px">
                            <tr class="blueBolderText">
                                <th class="style7">
                                    Date
                                </th>
                                <th class="style8">
                                    Cause of accident
                                </th>
                                <th>
                                    Driver
                                </th>
                                <th class="style9">
                                    Cost
                                </th>
                                <th>
                                    Insurer
                                </th>
                            </tr>
                            <tr>
                                <td class="style7">
                                    &nbsp;
                                    <input type="text" name="txbDate1" />
                                </td>
                                <td class="style8">
                                    &nbsp;
                                    <input type="text" name="txbCause1" />
                                </td>
                                <td>
                                    &nbsp;
                                    <input type="text" name="txbDriver1" />
                                </td>
                                <td class="style9">
                                    &nbsp;
                                    <input type="text" name="txbCost1" />
                                </td>
                                <td>
                                    &nbsp;
                                    <input type="text" name="txbInsurer1" />
                                </td>
                            </tr>
                            <tr>
                                <td class="style7">
                                    &nbsp;
                                    <input type="text" name="txbDate2" />
                                </td>
                                <td class="style8">
                                    &nbsp;
                                    <input type="text" name="txbCause2" />
                                </td>
                                <td>
                                    &nbsp;
                                    <input type="text" name="txbDriver2" />
                                </td>
                                <td class="style9">
                                    &nbsp;
                                    <input type="text" name="txbCost2" />
                                </td>
                                <td>
                                    &nbsp;
                                    <input type="text" name="txbInsurer2" />
                                </td>
                            </tr>
                            <tr>
                                <td class="style7">
                                    &nbsp;
                                    <input type="text" name="txbDate3" />
                                </td>
                                <td class="style8">
                                    &nbsp;
                                    <input type="text" name="txbCause3" />
                                </td>
                                <td>
                                    &nbsp;
                                    <input type="text" name="txbDriver3" />
                                </td>
                                <td class="style9">
                                    &nbsp;
                                    <input type="text" name="txbCost3" />
                                </td>
                                <td>
                                    &nbsp;
                                    <input type="text" name="txbInsurer3" />
                                </td>
                            </tr>
                        </table>
                    </div>
                    <div class="itemField">
                        <div class="listDiv">
                            What is the main purpose for which the vehicles will be used?
                        </div>
                        <div class="listDiv">
                            <input id="Text1" type="text" name="txbPurpose" runat="server"></asp:TextBox>
                        </div>
                    </div>
                    <div class="itemField">
                        <label>
                            Are any vehicles used for regular long haul journeys?
                        </label>
                        <div class="checkboxItemField">
                            <input type="radio" name="rbtnRegularLongHaul" value="Yes" />
                            <input type="radio" name="rbtnRegularLongHaul" value="No" />
                        </div>
                    </div>
                    <div class="itemField">
                        <label>
                            Are any vehicles operated for more than 10 hours per day?
                        </label>
                        <div class="checkboxItemField">
                            <input type="radio" name="rbtnVehiclesOperated" value="Yes" />
                            <input type="radio" name="rbtnVehiclesOperated" value="No" />
                        </div>
                    </div>
                    <div class="itemField">
                        <label>
                            Are any vehicles used for bulk transport of any hazardous substances?
                        </label>
                        <div class="checkboxItemField">
                            <input type="radio" name="rbtnVehiclesUsed" value="Yes" />
                            <input type="radio" name="rbtnVehiclesUsed" value="No" />
                        </div>
                    </div>
                    <div class="itemField">
                        <label>
                            Do you regularly hire vehicles or hire out your vehicles?
                        </label>
                        <div class="checkboxItemField">
                            <input type="radio" name="rbtnRegulerHireVehicles" value="Yes" />
                            <input type="radio" name="rbtnRegulerHireVehicles" value="No" />
                        </div>
                    </div>
            </fieldset>
            <fieldset>
                <legend>OPTIONAL EXTENSIONS </legend>
                <div class="itemField">
                    <label>
                        Do you require insurance for an agricultural implement or machine?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnRequireInsurence" value="Yes" />
                        <input type="radio" name="rbtnRequireInsurence" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Do you require a cover for hiring a substitute vehicle?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnSubstitute" value="Yes" />
                        <input type="radio" name="rbtnSubstitute" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Do you require cover for liability for rental vehicles?
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnCoverForLiability" value="Yes" />
                        <input type="radio" name="rbtnCoverForLiability" value="No" />
                    </div>
                </div>
            </fieldset>
            <fieldset>
                <legend>YOUR DECLARATION</legend>
                <div class="itemField">
                    <span class="blueBolderText">I declare that I:</span>
                </div>
                <div class="itemField">
                    <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>
                            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 other members
                            of the insurance industry, financially interested parties noted on the policy and
                            Insurance Claims Register Limited.
                        </ol>
                        <ol>
                            4.3 The disclosure of my personal information held by other members of the insurance
                            industry and Insurance Claims Register Limited to New India for the purpose of considering
                            this proposal and administering the policy. 5 Am authorized to complete this proposal
                            on behalf of anyone else to be insured under the policy, and agree that they give
                            the same declarations. Signature of Proposer
                        </ol>
                    </ul>
                </div>
            </fieldset>
        </div>
    </div>
</div>