Personal Lines | Commercial Lines | Protection
To be completed by the Insurance Agent
Agent’s name Ageas agency number
Agent’s reference (if any) Quote Reference (if any)
Insurance required from (period of 12 months) Premium
Contract type Standard Economy
Introductory discount? YES No
To be completed by the Proposer
PLEASE USE BLoCK CAPITALS AND ANSWER ALL QUESTIoNS IN FULL
1. Your details
Title First name(s)
Family (or company) name
Post code of where vehicle kept overnight
2. Vehicle details
Make & model
Right hand Engine GVW Purchase Est. value Est. annual Current No. of Body Year of Registration
drive? capacity date mileage mileage seats type make number
Do you own the vehicle? YES No
If ‘No’ give details
Are you the registered keeper? YES No
If ‘No’ give details
Has the vehicle been adapted, altered or modified from the maker’s specification, such as having alloy wheels
fitted, additions to the bodywork, or changes affecting performance, suspension or brakes or had optional YES No
If ‘Yes’ give details
Has the vehicle been fitted with an alarm, immobiliser or tracking device which is not fitted as standard? YES No
If ‘Yes’ give name of device including exact model
Where is the vehicle kept overnight when at the usual address e.g. Drive / Garage / Public Road
3. Cover required
Comprehensive Third Party Fire & Theft Third Party only
Do you wish to pay the first part of any claim for damage to your vehicle? YES No
If ‘Yes’, indicate amount: £
This will be in addition to any other amount we may require you to pay.
4. Use required (see page 5 for details or ask your agent for advice)
Social Domestic and Pleasure (including commuting to and from a place of work) YES No
Carriage of own goods YES No
Carriage of goods for hire or reward YES No
5. Previous insurance details
Previous insurer Policy number Expiry date
Number of years No Claim Discount earned
If 4 years or more, do you wish to have your discount protected? YES No
Type of policy bonus earned on
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6. Drivers required
The drivers named below YES No
Any driver aged 30 years or over YES No
Please give details of yourself and all other drivers.
Drivers aged younger than 30 will NOT be covered unless their details are shown below.
Driver 1 Driver 2 Driver 3 Driver 4 Driver 5
State MALE or FEMALE
Relationship to Driver 1 (you) Policyholder
Date of Birth
occupation (Give full and part time occupations)
Type of licence held (Full U.K. etc)
Number of years licence held
Will the driver use the vehicle for commuting?
Is the driver the main user?
Does the driver own any other vehicle?
Does the driver have use of any other vehicle?
Has the driver ever been refused insurance or had their
Has the driver been involved in any accident or had a vehicle
damaged or stolen, regardless of who was at fault or whether
a claim was made, within the last three years?
If ‘Yes’ please give details in 7 below.
Has the driver been convicted of any motoring offence,
including fixed penalty offences, within the past 5 years?
If ‘Yes’ please give details in 8 below.
Has the driver been convicted for a non-motoring offence?
Does the driver suffer from any physical or mental disability,
illness or medical condition (e.g. diabetes, heart condition,
loss of limb)? If ‘Yes’ please give details in 9 below.
7. Accidents, claims or losses
Driver’s name Date of incident Brief details of what happened Fault? Was NCD affected?
(Yes or No) (Yes or No)
Driver’s name Conviction date offence code (see licence) Points Fine Length of any disqualification
9. Disabilities and medical conditions
Driver’s name Condition Date Diagnosed Is the DVLA aware
of this condition?
CV004 Nov 2010 3
Important notes: to a claim. Data from the Motor Insurance Database (MID)
1. Your policy will be based on the information provided in may be used to establish whether a driver is insured to drive a
this proposal form. vehicle and/or for preventing or detecting crime. If you are
involved in an accident in the UK or abroad, the MID may be
2. Failure to disclose all material facts could render your searched to obtain relevant policy information. You can find
insurance invalid and not give protection in the event of a out more at www.mib.org.uk. You should show this notice to
claim. Material facts are those which we would regard as anyone insured to drive the vehicle covered under the policy.
likely to influence the acceptance and assessment of this
Proposal. If you are in any doubt about the facts If premiums are paid by instalments, information may be
considered material, you should disclose them. We will be shared with other companies through credit reference
happy to give you advice if you wish. agencies. Such information is used to make lending
decisions and, on occasion, to prevent fraud.
3. It is an offence under the Road Traffic Act to make a false
statement or withhold any material information for the Further information
purposes of obtaining a Certificate of Motor Insurance. You are entitled to receive a copy of the information we hold
about you. Please contact our Data Protection officer, giving
4. We recommend that you keep a copy of this Proposal and your name, address and insurance policy number. We are
a record of all information (including copies of any letter or entitled to charge you a small administrative fee for this.
other documents) supplied to us. We will give you a
photocopy of this Proposal if you ask us within 3 months Declaration
of the start of cover. I/We declare that to the best of my/our knowledge and belief
the information I/we have given is true and complete.
5. Cover will not start until an Ageas Certificate of Motor
Insurance or Cover Note is issued. I/We agree to accept a Van Guard Policy in the form currently
issued by Ageas Insurance Limited.
6. Ageas reserves the right to decline this Proposal or to offer
a policy containing restrictions in cover. I/We understand that you will pass the information on this
form and about any incident I/we may give details of to other
7. Unless we agree otherwise, English law will apply to this interested parties, so that they can make it available to other
contract of insurance. insurers. I/we also understand that, in response to any
searches you may make in connection with this application or
8. A specimen of our current policy is available on request. any incident I/we have given details of, information may be
passed to you which has been received from other insurers
Data protection about other incidents anyone insured to drive the vehicle
We may use information we hold about you to contact you covered under the policy have been involved in.
about Insurance. Information may be used by us, other
companies in the Ageas group and by our agents and service I/We give consent for you to exchange information with the
partners acting under our instruction for the purpose of Police where this is needed to validate a claim.
arranging and handling your insurance policy, and to make
sure that any claim is settled effectively. We may use
information for research, marketing or statistical purposes. Signature of proposer
We will not use your information or pass it on to any other
person for the purpose of marketing any further products or
services to you.
We may share your personal information with operators of
registers used by the insurance industry to check information
and prevent fraudulent claims. These include the Claims and
Underwriting Exchange register, and the Motor Insurance
Anti-Fraud and Theft Register and the Motor Insurance Date
Database. We may pass information relating to your
insurance policy and any incident (such as an accident or
theft), to the operators of these registers. Under the
conditions of your policy, you must tell us about any incident
(such as an accident or theft) which may or may not give rise
CV004 Nov 2010 4
Use required - See section 4 of the proposal ONECALL - 0845 122 3260
This is a description of the uses available in section 4. Claims helpline open 24 hours a day, 365 days a year
Please ensure you choose the correct option. If you need onecall is a first-response service with operators that can
further help please ask your insurance adviser. immediately confirm whether your policy covers you for an
Social Domestic and Pleasure
Use for social, domestic and pleasure purposes (including Should your vehicle be involved in an accident, phone us
commuting to or from a place of work). directly and we will validate your claim and discuss with you
how your claim will be progressed.
The policy does not cover use for any business purpose, Message relay
hiring, racing, pace making, competitions, rallies, motor sport We can pass messages to friends, family or colleagues.
or for the motor trade other than for the purpose of servicing
or repairing the vehicle. Repair service
If your vehicle can be repaired, we will arrange for one of our
Carriage of own Goods approved repairers to contact you to arrange collection of
Use for social, domestic and pleasure purposes (including your vehicle in order that repairs may proceed.
commuting) and in connection with the policyholder’s
business or profession. • There is no need for you to get estimates.
• once your vehicle has been repaired, it will be delivered
Exclusions back to you.
The policy does not cover use for the carriage of goods and/
or passengers for hire or reward, racing, competition rallies Replacement Vehicle Service
or trials. - Comprehensive Policyholders only
For comprehensive policyholders only, as a contribution to
Carriage of Goods for Hire or Reward keeping you mobile, we will arrange for a supplier to provide
Use for social, domestic and pleasure purposes (including you with a replacement vehicle in the event of the vehicle
commuting) and in connection with the policyholder’s being unroadworthy following an accident. The vehicle
business or profession. supplied will be a:
• Car-derived style van where the vehicle is a light goods
Exclusions vehicle up to 1.8 tonne gross vehicle weight; or
The policy does not cover use for the carriage of passengers • Panel Van where the vehicle is a light goods vehicle
for hire or reward, racing, competition rallies or trials. between 1.8 and 3.5 tonne gross vehicle weight
Customer service The supplier will supply the replacement vehicle for a
We do everything possible to ensure that all persons taking maximum of 7 days, while the vehicle is being repaired, or a
out Van Guard are provided with the high standard of service settlement offer is made by us where the vehicle is deemed
they would expect of us. In the event that you have any to be a total loss.
cause for dissatisfaction in relation to your insurance policy,
please write to the customer service advisor at our registered The service described above is subject to the availability of a
address. These procedures do not affect your legal rights. suitable replacement vehicle from the supplier. Whilst every
reasonable effort will be made to supply a replacement
Please see the policy wording for our full complaints vehicle, neither us nor the supplier will be liable to pay any
procedure. compensation, or provide a vehicle from another source
should a suitable vehicle be unavailable.
The notes above are a summary of the cover we will provide,
full details are referred to in the policy booklet.
5 CV004 Nov 2010
Ageas Insurance Limited
Ageas House, The Square,
Gloucester Business Park, Brockworth,
Gloucester GL3 4AD
Ageas House, Tollgate, Eastleigh,
Hampshire So53 3YA
Registered number 354568
Ageas Insurance Limited is authorised
and regulated by the Financial Services
6 CV004 Nov 2010