P L E A S E A N S W E R A L L Q U E S T I O N S I N C A P I TA L L E T T E R S
1 Name of Proposer in full:
Address or Registered Office:
Business or occupation:
2 (if more than one, state all)
Business or occupation:
(for the purpose of this insurance)
Please describe the full extent of your Motor Trade activities
3 (e.g. vehicle sales, repair, servicing, testing, breaking, sale of fuel, filling station proprietor etc.)
4 Are you a member of any motor trade association?
4 (If Yes, which?)
F O R O F F I C E U S E O N LY
Period of insurance FROM Time
Agency No. & Chk Ltrs
The insurer with which your contract will be concluded is Aviva Insurance Europe SE
(“the Company”). Aviva Insurance Europe SE is regulated by the Financial Regulator. The insurance will not
be in place until the proposal has been accepted by the Company. The Company reserves the right to
decline any proposal.
NO CLAIM DISCOUNT
In respect of Sections 1 and 2 a rebate in accordance with the following scale is allowed off the net renewal
premium in the event of no claim being made or arising during the preceding year(s) of insurance.
The preceding year - 15%
The preceding two consecutive years - 20% The preceding four consecutive years - 35%
The preceding three consecutive years - 30% The preceding five consecutive years - 40%
Section 1 General
YES NO YES NO
5 Are you insured or have you ever been insured in 8 (a) Have there been any accidents or losses during the
respect of any motor vehicle including motor vehicle past 5 years which occurred
road risk? (i) in connection with use of motor vehicles owned
If Yes, please state the name of every insurer concerned or driven or used by you
(ii) in on or about your premises?
(b) If Yes, give particulars in the schedule below of all such
*accidents and losses.
*All accidents whether resulting in a claim or not must be included.
Total No. Motor Vehicles Motor Trade
12 Months ending of Accidents (Road Risks) (Internal)
6 Are you entitled to a No Claims Discount from your previous (Date) and Losses No. Amount No. Amount
insurers in respect of any of the covers now proposed for?
If Yes, how many years (Please provide proof). Outstanding…
YES NO Outstanding…
7 Has any insurer or underwriter ever: Paid…
(a) declined to quote you?
(b) required an increased premium? Paid…
(c) imposed special conditions? Outstanding…
(d) refused to renew your policy?
(e) cancelled your policy?
Please complete each section where you require cover
Section 2 Motor Road Risk Liability
This section provides the necessary Third Party cover you must have by law for use of vehicles owned by you or for which you are legally responsible with an
option to include Fire and Theft and Accidental Damage to such vehicles. Cover is extended to include vehicles used for demonstration or tuition purposes
whilst prospective customers are accompanied by you/your employee.
Whilst the standard cover is for vehicles used in connection with your business, use for social, domestic and pleasure purposes by specified drivers will be
considered if they work in the business and use vehicles owned by the proposer.
NOTE: Vehicles in the following class should not be included, as any insurance required for these must be separately arranged.
Vehicles used for Public/Private Hire or Self Drive. l Goods carrying vehicles used for hire or reward. l Vehicle Transporters. l Vehicles belonging
to individual partners or directors. l Vehicles belonging to employees. l Vehicles in which a partner or director or an employee is interested
under a hire purchase agreement. l Any other vehicle used other than for Motor Trade purposes.
1 Full particulars of all purposes for which the vehicle(s) will be used.
2 Do you wish the Insurance to extend outside this country?
(If so give particulars)
3 State how many sets of Trade Number Plates are in your possession and specify registration numbers.
4 State under each of the following classes the total number of vehicles owned by you for the purpose of sale, also vehicles being acquired by you
under a hire purchase agreement.
(i) Private Cars (ii) Commercial Vehicles (iii) Motorcycles
5 Are you an accredited Recovery Agent for any Organisation? Yes No
If Yes how many Breakdown Recovery Vehicles are owned by you?
(Please provide details of the Breakdown Recovery Vehicle in 6 below)
6 Description of all other vehicles (i.e. Breakdown/Own Goods Carrying vehicles/Motorcycles) owned by you and used solely in connection with your
business as a Motor Trader.
Carrying Proposers estimate of present
Registered letters Make and model of vehicle Type of body Year of capacity value including accessories
and number to be insured manufacture or H.P./C.C. and spare parts
YES NO (If YES, give details)
7 Will any vehicle be used for purposes other than in connection with your business as a MOTOR TRADER?
8 State scope of cover required under this section i.e.,
“Comprehensive” or “Third Party, Fire & Theft” or “Third Party Only”
Section 2 Motor Road Risk Liability (continued)
Give full details of all persons who may drive for the following purposes.
(i) Business use only - Code A (ii) Business and social domestic and pleasure - Code B (iii) Social/domestic and pleasure only - Code C Specify Use Code hereunder
Note: Social domestic and pleasure use is restricted to persons who have either held a full licence for three years or held a provisional licence in excess of five years and are Full Time Employees of the
Has any Driver a prosecution pending or
Name of Driver Type of licence currently held, Description Date Occupation any Penalty Points imposed on their Record of Have any insurers ever Has he/she defective
Country of Issue and number of use code of (If not employed in the licence or ever been convicted of any Accidents/Claims refused or cancelled vision or hearing or
of years held (i.e. Full, (A), (B) Birth proposer’s garage please motoring offence or had his/her licence during Past 5 yrs declined to renew his/her suffered at any time from
Provisional etc.) or (C) state occupation and relationship suspended? If so, state Date of Offence, of driving motor insurance or Diabetes, fits or heart
to proposer) Offence Type and Number of Penalty imposed special terms? complaint or infirmity
points Total Total If so, give full particulars If so, state details
Section 3 Public Liability (Premises) Risk
SECTION 2 – PUBLIC LIABILITY
A Motor Trader is liable for any injury or damage caused to persons or property of others by the negligence of himself or of his servants or through any defect
in the ways, works, machinery, plant or premises. There may be exceptional circumstances under which a trader may escape responsibility for such injury or
damage by reason of a denial of liability on his notepaper or the display of notices to that effect in his showrooms or works. It is seldom however, that the law
gives this relief and the trader should assume that, whether or not he makes use of such notices he will have to pay for injury or damage caused by his own
or his employee’s negligence.
This section applies to liabilities arising on the premises only and indemnity can be provided (with optional extensions) as follows:
* Bodily injury (€2,600,000 any one accident)
* Property damage (€2,600,000 any one accident)
* Damage to Own Vehicles (€65,000 any one accident)
* Damage to Customers Vehicles
* Liability arising from servicing of Motor Vehicles (€1,300,000 limit)
* Liability arising from sales of Motor Vehicles (€1,300,000 limit)
State total estimated Gross salaries, wages and all other earnings of the Proposer (if an individual) partners, directors and employees.
Description Estimated Gross Salaries, Wages
and all other Earnings
Shop Assistants €
Petrol Pump Attendants €
Property Repairs €
All others €
1b Please provide a breakdown of this figure
2 Please give particulars of premises to be insured: (a) Situation:
(b) Give capacity of premises reckoned in number of vehicles under each of the following headings.
Showroom area Garage Area Workshop Area In the open
3 Are the premises used for any purpose other than that of a showroom, garage, workshop or car park? If YES please state such other purposes
4 Are all of the openings in floor or pavement guarded, and if so in what manner?
5 Of what materials are the premises constructed?
6 Is petrol stored on the premises If Yes, state amount
7 If you have car wash facilities please state number of bays/booths
8 Your Activities:
Do You YES NO
(a) Hold a dealership appointment
for a particular marque? If YES, please state which?
(b) Export vehicles? If YES, please state turnover and countries concerned?
(c) Import vehicles? If YES, please state turnover and countries concerned?
(d) Undertake or specialise in YES NO
(i) the sale or repair of commercial vehicles, public service vehicles, agricultural vehicles or contractors plant?
(ii) vehicle body building?
Section 3 Public Liability (Premises) Risk continued
(iii) vehicle breaking?
(iv) the manufacture or re-manufacture of vehicle parts and accessories?
(v) any other activity at or from the premises?
If YES to any of above, please give full details and the percentage as a proportion of overall activities.
9 YES NO
Have you entered into any agreement assuming liability for injury, illness, loss or damage for which you would
not have been liable in the absence of such agreement? If YES give details.
10 YES NO
Do you sub-contract work to established firms or companies or employ any other sub-contractors,
labour masters or self employed persons?
If you have answered ‘YES’ give details of work done by them and confirm that you ensure they have adequate liability insurance in force. Please
indicate the Limit of Indemnity on sub-contractors insurance.
11 Do you require insurance extended to include any of the following extensions? YES NO
A Loss of or damage to your vehicles or those of Persons Employed or members of your family or household whilst such vehicles are at your premises
B Liability arising from servicing of motor vehicles
C Liability arising from the sales and servicing of motor vehicles (see 12 below)
D Liability arising from sale or supply of lubrication or fuel oil petrol or water directly into motor vehicles (see 12 below)
E Motor Trade Professional Indemnity (see 13 below)
(NB: Cover for liability arising from servicing of vehicles is subject to warranty that work is checked by a qualified mechanic.)
12 If YES to C or D above, please state your annual turnover under the following headings
New Vehicles € Secondhand vehicles € New and remould tyres € All other products €
13 If YES to E above, please complete the following questions relating to Motor Trade Professional Indemnity.
(NB: Please note this cover is in respect of the provision of advice or services by the Proposer in relation to any Insurance Mediation Activity in
connection with any insurance product relating to a Motor Vehicle ONLY).
(i) Have you or are you in the process of registration with IFSRA?
(ii) IFSRA Registration Number
(iii) Business for the purpose of this Professional Indemnity Insurance?
The provision of advice or services by the Proposer in relation to any Insurance Mediation Activity in connection with any
insurance product relating to a Motor Vehicle.
(iv) Is your retained income relating to insurance received in their last completed financial year above €100,000?
(Retained income is defined as annual income less the cost of the product paid to the provider/insurer)
If ‘YES’ please provide details.
Please provide details of the firm’s retained insurance income below
Annual Income Retained Income
Creditor Protection Insurnace € €
GAP & Vehicle Asset Protection € €
Insured Warranties and Extended Warranties € €
Tyre and Exhaust Insurance € €
MOT Insurance € €
Key Fob Insurance € €
Breakdown Recovery Insurance € €
Motor Insurance (including “free insurance”supplied with car
sales and insurance purchased by customers with rental cars)
Other (Please specify): € €
Total Income € €
Section 3 Public Liability (Premises) Risk continued
(v) Do you propose to operate a Client Premium Account?
(vi) Have all staff who deal with Insurance related matters received training and are competent to do so?
(vii) Will all staff who deal with Insurance related matters meet the IFSRA Training and Competence requirements?
(viii) Who provided this training and if required can you provide a record of training received?
(ix) During the last 5 years, have any claims (of the type that would be covered under this insurance) been made against you or the proposers firm
or their predecessors in business or any of their present or former principals, partners, directors or employees?
(x) Are any of the principals, partners or directors aware of any circumstances, allegations or incidents which may give rise to a claim against their
firm or it’s predecessors in business or any of it’s present or former principals, partners, directors or employees?
(xi) Have any complaints, circumstances or claims arisen as a result of any fraud or dishonesty of any principals, business partner, director or
employee of the proposers firm/company or if the proposer is a natural person any such complaints, circumstances or claims that have arisen is
related to him/her or their business partners? If so please specify.
Section 4 Engineering
Under existing laws, certain plant must be thoroughly examined at specified intervals by a “competent person” and report thereof entered in the general
Aviva can provide an inspection service through its countrywide network of Engineer Surveyors and issues reports as prescribed by Statute.
Machinery/equipment-related insurance is also available.
If you wish us to supply a quotation, please indicate below the class of plant concerned (tick appropriate boxes).
Pressure Plant Air Compressor (Receiver) Other
Lifting Machinery Fork-lift Trucks Vehicle Lifting Tables Block and Tackle Hoists Floor Cranes Other
If not, what arrangements have you Please advise Expiry Date of any
in operation to meet these requirements? existing contract/policy:
Additional Information (if any)
You must tell us any other facts which are likely to affect whether we agree to provide cover, or how we assess the risks proposed for insurance. If you are not sure whether you
should tell us about something, please tell us anyway. This is for your own protection because, if you do not give us all the information we need, your policy may not provide
you with the cover you need, or the policy could be declared invalid and void.
Warning: As it is an offence under the Road Traffic Act to make any false statement or withhold information to get a certificate of insurance, you should make sure that you answer all questions
fully and accurately. If the proposer is a firm or a private company, you must read and answer the questions as though they also apply to each individual partner or member
Under the third EU Non-life Directive we must give you the following information before you buy your policy.
The law that applies to the contract - Under the relevant European and Irish laws, we Aviva Insurance Europe SE and you, the proposer, are free to choose the law that will apply to the contract.
We propose that Irish law will apply to the contract. We, Aviva Insurance Europe SE, will provide the insurance under this policy.
Complaints procedure - We aim to give excellent service to all our customers; however, we recognise that things may occasionally go wrong. We will do our best to deal with
your complaint as effectively and quickly as possible. If you arranged your cover through an agent or adviser, please send your complaint to them. If your complaint is not sorted
out to your satisfaction, please contact:
Customer Feedback Team, Aviva Insurance Europe SE, One Park Place, Hatch Street, Dublin 2
CallSave: 1850 36 37 38
You can also write to the Managing Director, Aviva Insurance Europe SE, One Park Place, Hatch Street, Dublin 2 or you can contact the following
• The Irish Insurance Federation’s Insurance Information Service, 39 Molesworth Street, Dublin 2
Phone: 01 676 1914
Fax: 01 676 1943
• The Financial Services Ombudsman Bureau, 3rd Floor, Lincoln House, Lincoln Place, Dublin 2
Phone: 01 662 0899
LoCall: 1890 88 20 90
Fax: 01 662 0890
You will not lose your right to take legal action if you contact either of the above.
DATA PROTECTION - Aviva Insurance Europe SE (“we”, “us” or “our”), as data controller, will keep the information you provide about yourself and about third parties confidential. We
may use it to advise on, provide and administer insurance products and financial services provided by us or other Aviva companies and sometimes with our affiliates and/or commercial
partners, in order to comply with legal obligations imposed on us. We may share the information both inside and outside of the European Economic Area, in confidence, for these
purposes with agents or service providers we have appointed, private investigators, regulatory organisations, other insurance and financial services companies (directly or via a central
register), other Aviva group companies, those to whom we outsource certain business operations and as required by law. We will process this information and store it on our computer
and manual record systems.
To assist in preventing, detecting and/or protecting our customers and ourselves from theft and fraud, we may use your information to make searches of our or other Aviva companies’
records. If you give us false information or fail to disclose information and we suspect fraud, we will record this. We also participate in industry databases such as those operated by the
Irish Insurance Federation for the purpose of sharing of information among insurance companies as a check against non-disclosure.
From time to time, we may record your telephone calls for verification and training purposes.
If you would like a copy of the details we hold about you, please write to the Regulation and Compliance Manager, Aviva Insurance Europe SE, One Park Place, Hatch Street, Dublin 2.
Please enclose the correct fee (€6.35). You also have the right to correct any errors in the information held about you, block certain uses or object to the processing of your personal data.
Important: Some of the questions on this form may ask for details about your health and convictions and the health and convictions of third parties material to this risk – please do not
send us any genetic test results. This information is important for underwriting and claims purposes and will remain confidential. By signing the declaration below, you are giving us
permission to process these details for the above purposes, including checking with third parties or accessing State or other official records to verify whether the details you have given are
accurate and complete. By signing below, you are confirming that you have fully explained to each person who requires this insurance cover why we asked for this information and what
we will use it for. You are also confirming each person has agreed to this.
ONLY SIGN THE FOLLOWING DECLARATION IF YOU FULLY UNDERSTAND, AND HAVE MET, ALL OF THE ABOVE REQUIREMENTS.
Declaration – I/We confirm that, all the details, answers and information given in this proposal are true, accurate and complete. I acknowledge that this proposal will form the basis of
my/our contract with Aviva Insurance Europe SE. I/We confirm that I/we am/are giving my/our permission to you to use the information I/we have given on this form for the purposes set
out in the Data Protection section above.
Your Signature: Date: / /
We would like to use your details to provide you with information about other financial or insurance products, services and special offers either from us or other Aviva
group companies, or products, services and special offers which any member of the Aviva Group may arrange with a third party. Your details may also be used for this
purpose (for up to 12 months) after your policy has ceased. Please tick here I if you do not wish to receive such information from us.
Your choice will not affect any of the services we provide to you, now or in the future.
Aviva is the world’s fifth largest* insurance group, serving 53 million
customers across Europe, North America and Asia Pacific. In Ireland
1.2 million customers trust us to look after their financial and
We are very proud of our established and trusted heritage in Ireland
spanning over 100 years. We are committed to understanding our
customers, recognising their individual needs and providing world-
class service through our nationwide network of branches and
independent brokers together with our customer contact centre
and website www.aviva.ie
From our breadth of products and range of innovative benefits to
our dedication to providing security, quality and value, we are
continuously developing our products and services to meet our
*based on gross worldwide premiums at 31 December 2008
For our joint protection, we may record and
monitor phone calls.
Aviva Insurance Europe SE
Phone 01 898 8000 E-mail email@example.com Website: www.aviva.ie
Registered in Ireland number 3319 Registered Office: One Park Place, Hatch Street, Dublin 2.
Aviva Insurance Europe SE is regulated by the Financial Regulator
and is a member of the Irish Insurance Federation