Diyadio WebForms :: Webform Designer

Form name:

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                BOAT INSURANCE PROPOSAL
                <p>
                    No risk attaches until the proposal has been accepted by the company and premium
                    is paid or agreed to be paid
                </p>
            </div>
        </div>
        <fieldset>
            <legend>YOUR DETAILS </legend>
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                    Full name:<span class="redText">*</span>
                </div>
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                    <input type="text" name="txbFullName" />
                </div>
            </div>
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                    Your address:<span class="redText">*</span>
                </div>
                <div class="listDiv">
                    <textarea name="txbYourAddress" cols="22" rows="4"></textarea>
                </div>
            </div>
            <div class="itemField">
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                    Occupation:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbOccupation" />
                </div>
            </div>
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                <strong>Contact details:</strong>
            </div>
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                    Address:
                </div>
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                    <textarea name="txbAddress" cols="22" rows="4"></textarea>
                </div>
            </div>
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                Telephone</div>
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                    Work:</div>
                <div class="listDiv">
                    <input type="text" name="txbWork" />
                </div>
            </div>
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                    Home:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbHome" />
                </div>
            </div>
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                    Mobile:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbMobile" />
                </div>
            </div>
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                    Email:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbEmail" />
                </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:
                <ul>
                    <ol>
                        • Whether to accept your proposal, and</ol>
                    <ol>
                        • If so, on what terms.
                    </ol>
                    <ol>
                        Examples of what you must tell us include:
                    </ol>
                    <ol>
                        • Anything that increases the risk of a claim</ol>
                    <ol>
                        • Any criminal offending or convictions</ol>
                    <ol>
                        • Any previous insurance claims</ol>
                    <ol>
                        • Any refusal by another insurer to insure you on standard terms, or continue to
                        insure you on standard terms.</ol>
                </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>
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                We collect and receive your personal information in this proposal to decide whether
                to insure you. We hold it in our records. 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>
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                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="rblInsurer" value="Yes" />
                    <input type="radio" name="rblInsurer" 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="rblInsurenceClaim" value="Yes" />
                    <input type="radio" name="rblInsurenceClaim" 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="rblInsurenceinFiveYears" value="Yes" />
                    <input type="radio" name="rblInsurenceinFiveYears" 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="rblCircumstances" value="Yes" />
                    <input type="radio" name="rblCircumstances" 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="rblCriminalConvictions" value="Yes" />
                    <input type="radio" name="rblCriminalConvictions" value=" No" />
                    <br />
                    <br />
                    <textarea name="txbAnswer" rows="5" cols="55"></textarea>
                </div>
                <div class="itemField">
                    If you have answered yes to any of the above questions, please write full details
                    below
                    <br />
                    <textarea name="txbAnswers" rows="5" cols="55"></textarea>
                </div>
                <div class="itemField">
                    <label>
                        Please advise what type of boat you have:
                    </label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnBoatType" value="Yacht" />
                        <input type="radio" name="rbtnBoatType" value=" Launch" />
                        <input type="radio" name="rbtnBoatType" value="Other" />
                    </div>
                </div>
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                    <strong>Please Advice</strong>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Model/design
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbModelDesign" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Hull structure
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbHull" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Designer</div>
                    <div class="listDiv">
                        <input type="text" name="txbDesigner" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Boat builder
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbBoatbuilder" />
                    </div>
                </div>
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                        Year constructed.
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbConstructed" />
                    </div>
                </div>
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                        Length
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbAdviceLength" />
                    </div>
                </div>
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                    <div class="listDiv">
                        Beam.
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbBeam" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Draft</div>
                    <div class="listDiv">
                        <input type="text" name="txbDraft" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Max hull speed
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbMaxHull" />
                    </div>
                </div>
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                    <strong>Cooking facilities:</strong>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Gas</div>
                    <div class="listDiv">
                        <input type="text" name="txbGas" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Spirits</div>
                    <div class="listDiv">
                        <input type="text" name="txbSpirits" />
                    </div>
                </div>
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                    <div class="listDiv">
                        Electric
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbElectric" />
                    </div>
                </div>
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                    <div class="listDiv">
                        Other</div>
                    <div class="listDiv">
                        <input type="text" name="txbCookinOther" />
                    </div>
                </div>
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                    <div class="listDiv">
                        None
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbNone" />
                    </div>
                </div>
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                    <strong>Engine specifications</strong>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Make
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbMake" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Model
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbModel" />
                    </div>
                </div>
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                    <div class="listDiv">
                        Year built
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbYearBuilt" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Serial number
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbSerialNumber" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Inboard/outboard</div>
                    <div class="listDiv">
                        <input type="text" name="txbInBoard" />
                    </div>
                </div>
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                    <div class="listDiv">
                        Power source
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbPower" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Fuel type
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbFuelType" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Type and size of fuel tank:
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbTypeAndSize" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Auxiliary power source
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbAuxilary" />
                    </div>
                </div>
                <div class="itemField">
                    <strong>Trailer</strong>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Make
                    </div>
                    <div class="listDiv">
                        <input type="text" name="txbTrailerMake" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Model</div>
                    <div class="listDiv">
                        <input type="text" name="txbTrailerModel" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Year built</div>
                    <div class="listDiv">
                        <input type="text" name="txbTrailerYearBuilt" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Serial number</div>
                    <div class="listDiv">
                        <input type="text" name="txbTrailerSerialNumber" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Braked</label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnBraked" value="Yes" />
                        <input type="radio" name="rbtnBraked" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <label>
                        Secured</label>
                    <div class="checkboxItemField">
                        <input type="radio" name="rbtnSecured" value="Yes" />
                        <input type="radio" name="rbtnSecured" value="No" />
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv">
                        Describe, if yes</div>
                    <div class="listDiv">
                        <textarea name="txbSecured" rows="5" cols="55"></textarea>
                    </div>
                </div>
            </div>
            <div class="itemField">
                <strong>Accessories</strong>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Dinghy? If so, provide details of:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbDinghy" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Type
                </div>
                <div class="listDiv">
                    <input type="text" name="txbType" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Length
                </div>
                <div class="listDiv">
                    <input type="text" name="txbLength" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Sum/value</div>
                <div class="listDiv">
                    <input type="text" name="txbSumValue" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Fishing gear? If so, provide details
                </div>
                <div class="listDiv">
                    <textarea name="txbFishing" rows="5" cols="55"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Sail gear? If so, provide details
                </div>
                <div class="listDiv">
                    <textarea name="txbSail" rows="5" cols="55"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Personal contents normally kept on board? If so, provide details:
                </div>
                <div class="listDiv">
                    <textarea name="txbPersonal" rows="5" cols="55"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Mooring? If so, advice:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbMoorings" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Type and location
                </div>
                <div class="listDiv">
                    <input type="text" name="txbTypeAndLocation" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Date mooring last inspected.
                </div>
                <div class="listDiv">
                    <input type="text" name="txbDateMoorings" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Inspected by</div>
                <div class="listDiv">
                    <input type="text" name="txbInspect" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Date and frequency boat slipped out of water?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbFrequency" />
                </div>
            </div>
            <div class="itemField">
                <label>
                    Is your boat used for charter/hire?
                </label>
                <div class="checkboxItemField">
                    <input type="radio" name="rbtnCharter" value="Yes" />
                    <input type="radio" name="rbtnCharter" value="No" />
                </div>
            </div>
            <div class="itemField">
                <strong>Racing</strong></div>
            <div class="itemField">
                <label>
                    Do you require cover for racing?
                </label>
                <div class="checkboxItemField">
                    <input type="radio" name="rbtnCoverRacing" value="Yes" />
                    <input type="radio" name="rbtnCoverRacing" value="No" />
                </div>
            </div>
            <div class="itemField">
                <strong>Experience</strong></div>
            <div class="itemField">
                <div class="listDiv">
                    Please describe your boating experience/qualifications:
                </div>
                <div class="listDiv">
                    <textarea name="txbBoatingExperiance" rows="5" cols="55"></textarea>
                </div>
            </div>
            <div class="itemField">
                <label>
                    Have you and/or your boat been in an accident in the last five years?
                </label>
                <div class="checkboxItemField">
                    <input type="radio" name="rbtnAccident" value="Yes" />
                    <input type="radio" name="rbtnAccident" value="No" />
                </div>
            </div>
            <div class="itemField">
                If Yes, please describe<textarea name="txbDescribe" rows="5" cols="55"></textarea>
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR DECLARATION</legend>
            <div class="itemField">
                I declare that I:
                <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 to complete this proposal on behalf of anyone else to be insured
                        under the policy, and agree that they give the same declarations.
                    </ol>
                </ul>
            </div>
        </fieldset>
    </div>
</div>