_ _ MOTOR VEHICLE INSURANCE PROPOSAL FORM by sofiaie

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                                           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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