VIEWS: 72 PAGES: 2 POSTED ON: 3/16/2010
! " # MOTOR VEHICLE INSURANCE PROPOSAL FORM ! ! !"#$ OPERATIVE INSURANCE COVER REQUIRED Comprehensive Third Party Legal Liabilities ! Period of Insurance From To !"=PARTICULARS OF PROPOSER L L Insured / Proposer Mr / Mrs /Miss !"#$ Insured's Business Position Home Address ! Home Tel. ! Business Address !"# Daytime Tel. !"#$%&'(#)*+, Hire Purchase Owner (if any) !"#$ PARTICULARS OF MOTOR VEHICLE TO BE INSURED ! !" ! ! ! !"# Registration Mark Vehicle Make Vehicle Model Type of Body Engine Number Chassis Number !=EÅKÅKF ! !" =E F !"#=E L F Cylinder Capacity (c.c.) Year of Manufacture Gross Vehicle Weight Seating Capacity (incl. Driver) Anti-Theft Alarm System (Model / Value) !"#$%&'=E !"# $F Estimated Value of the Motor Vehicle including Accessories (Sum Insured) !"#$%&'()*+,=E ! ehAOIMMM !"F Please detail all accessories that are not factory-fitted (except items that cost less than HK$2,000): !"#$%&'()*=PARTICULARS OF DRIVERS WHO WILL REGULARLY DRIVE THE MOTOR VEHICLE !" !"#$% !"# !" !"# Full Name of Driver Nominated as Age Relationship Occupation HK ID Card Number of years has Driver Named Driver? with Proposer Number been regularly driving ENF vÉë kç EOF vÉë kç EPF vÉë kç EQF vÉë kç !"#$=J= !"#$%& ✔ =USE OF THE MOTOR VEHICLE - Please "✔" more than one if applicable : - !=cçê=ëçÅá~ä=ÇçãÉëíáÅ=~åÇ=éäÉ~ëìêÉ=éìêéçëÉë !"#=få=ÅçååÉÅíáçå=ïáíÜ=íÜÉ=jçíçê=qê~ÇÉ !=cçê=ÄìëáåÉëë=éêçÑÉëëáçå~ä=ìëÉ=çê=Ñçê=ìëÉ=Äó=ÉãéäçóÉÉë !"#$=cçê=ÜáêÉ=çê=êÉï~êÇ !"#$ MKT/MVI/06 mKqKlK !"#$%&'()=J= !"#$%& ✔ =PLEASE "✔" CORRECT ANSWERS TO FOLLOWING QUESTIONS N !"#$%&'()*+,-,./0,12345 Has the Motor Vehicle been modified in any way from manufacturers' standard specifications? Yes No O !"#$%&'()*+,-./0123456789:;< Have you or any person who to your knowledge may drive the Motor Vehicle been involved in any traffic accident during the last 3 years? Yes No P !"#$%&'()* OQ !"#$%&'(!)*+,$%-./0 NO \= !"#$%&'() Have any of the above drivers ever been disqualified or accumulated more than 12 driving offence points in the last 24 months? Yes No If Yes please give full details Q !"#$%&'()*+,-./0 12%345)*!"6789:!;89<!;=>?@AB!";(C !"#$%&'()* In respect of Motor Insurance, have you or has any person who to your knowledge may drive the Motor Vehicle been declined such Yes No application, or been Refused renewal, or been terminated such insurance, or been imposed special terms on your/his/her policy by any insurance company? R !"#$%&'()*+,-#./012 !"345678 9:1;<= Do you or does any person who to your knowledge may drive the Motor Vehicle suffer from defective vision or hearing or from any physical or Yes No mental infirmity? ENF ERF !"#$%& !"#$ If the answer to any of the above questions (1) to (5) is "Yes", please give details ! !"#$%& Ek`aF= !"#$=J= !"#$ DETAILS OF PRESENT MOTOR INSURANCE "NO CLAIM DISCOUNT" (NCD) - Please supply documentary evidence : !"# k`a !"# !"# k`a !"#$%&'( Registration Mark of Motor NCD (%) Name of Insurer Present Policy Number Transfer the NCD to the Motor Vehicle Vehicle proposed here? vÉë kç DECLARATION L !"#$%&'()* +',-./01234567 I/We desire to insure with CAF International Insurance Company Limited ("the Company") in respect of the Motor Vehicle as detailed herein and hereby declare that : ENF !"#$%& the Motor Vehicle is in good condition; EOF !"#$%&'())*+,-./0123+,-.456+,7 the Motor Vehicle will not be driven by any person who to my/our knowledge does not hold a full valid driving licence or has been disqualified from holding such driving licence; EPF !"#$%&'()*+,-./ L !"#$%&'()* the particulars given in this Proposal Form are true and nothing materially affecting the insurance risk has been concealed by me/us; EQF !"#$%&'()*+,- ./01*234 56789:;. L !"#$%&'()*+ $,-"./ if any particulars or answers in this Proposal Form are not in my/our hand-writing, the person or persons filling in such particulars and answers shall be deemed to be my/our agent for that purpose; ERF L !"#$%&'()*+, - L !"#$%&'()*+,-./ I/We hereby agree that this Proposal and Declaration shall be incorporated in and taken as the basis of the proposed contract between me/us and the Company; and ESF L !"#$%&'()*+,-./012)*34 I/We agree to accept a policy in the Company's usual insurance policy form for this class of insurance. !"=Proposer's Signature =Date !"#=The Company Uses only !" ENF !"# $%&'()*+,&-./012345 67489:;<=&>?@ABCDE*&FGH IJKL Important Failure to supply true answers to this Proposal Form or inform the Company of all material information about your insurance proposal Notices may render the insurance policy invalid. EOF !"#$%&'()*E~F !"#EÄF !"#$%&'(EÅF !"#$%&' !()* Please attach copy of (a) Vehicle Registration Document; (b) Owner's ID Card and Driving Licence; (c) Named Drivers' ID Card and Driving Licence. EPF !"#$ %&'()* + ,#-./0 1234567 The insurance will not commence until this proposal has accepted by this company and the first premium paid.
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