Docstoc

Combined Motor Trader Proposal

Document Sample
Combined Motor Trader Proposal Powered By Docstoc
					Combined Motor Trader Proposal
        Motor Traders
        Combined Insurance
        Proposal
                                   Policy Number




                                   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 B L O C K C A P I TA L 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.)




                     Situation(s) of property to be insured:
                4    (if different from postal address)

                     1.

                     2.
                     Are you a member of SIMI?
                5    (If Yes, please give Membership No.)



                     In addition to SIMI are you a member of any other motor trade association?
                6    (If Yes, which?)




                                                          F O R O F F I C E U S E O N LY

                 Period of insurance            FROM                                             Time

                                                TO

                 Renewal Date

                 Area/Branch

                 Area/Branch Number

                 Agency

                 Agency No. & Chk Ltrs



                                                                    NOTE:
               The insurer with which your contract will be concluded is Hibernian General Insurance Limited
               (“the Company”). Hibernian is a member of the Aviva plc group of companies. 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.
               A copy of this form is available on written request within three months of the date of completion. A specimen of
               the policy normally issued will be supplied on request.

                                                              SPECIAL NOTE:
               For our joint protection, telephone calls may be recorded and/or monitored.

                                                                  IMPORTANT:
               As is it an offence under the Road Traffic Act to make any false statement or withhold any material information
               for the purpose of obtaining a Certificate of Insurance, great care should be taken to ensure that all questions
               and subsections of questions are answered fully and accurately. If the proposer is a firm or private
               company, the questions are to be read and answered as also applying to each individual partner or member.
PF/030/07/06
     Section 1                                                                                                                       Material Damage

1A          Commercial All Risks
     Item No.                                                     Property to be Insured                                                                Sum Insured
        1          Building including:
                   (a) Landlord’s fixtures and fittings
                   (b) Kiosks, outbuildings and annexes                                                                                             €
                   (c) Walls, fences, gates, forecourts, canopies and fixed signs
        2          Machinery, plant, including fuel installations, and all other contents belonging to you or for which
                   you are responsible                                                                                                              €
        3          Stock and materials in trade (ex. Motor Vehicles) belonging to you or for which you are responsible
                   (Limit Radios/Audio/Visual Equipment €6,500)                                                                                     €
        4          Stock of tyres                                                                                                                   €
        5          Stock of Shop Insured
                   (Excluding wine, spirits, cigarettes or frozen food)                                                                             €
        6          Wines and spirits                                                                                                                €
        7          Cigarettes/Tobacco (Limited to €6,500)                                                                                           €
        8          Vehicles the property of the insured or leased in by the insured or held in trust for which they are responsible                 €
                   (Including Customer’s Vehicles)
        9          Portacabin                                                                                                                       €
       10          All Others (Please specify)                                                                                                      €

                                                                                                                          Total Sum Insured         €

                                                                                                                                                        YES or NO
Glass: If the building is not to be insured under this section indicate if you wish to insure Glass forming part of the buildings.
Note: If the building is insured under Item No. 1 above Glass will be automatically covered.




 A      CONSTRUCTION                                                      YES   NO         E    OTHER INTERESTS                                          YES NO
        Are all the buildings constructed of brick, stone or                                    Is any other party (e.g. loan company) interested in any
        concrete and roofed with slate, tile, metal, asbestos,                                  item of this section? If ‘YES”, give details.
        cement sheets or concrete? If “NO’, give details                                        BUILDINGS / CONTENTS / STOCK / OTHERS (please circle item).
        _______________________________________________________                                 Name & Address of Interested Party:
        _______________________________________________________                                  _______________________________________________________
        _______________________________________________________                                  _______________________________________________________


 B      HEATING                                                           YES   NO              Note 1:     Owing to the effects of the average clause, applicable to
        Do you use any artificial methods of heating or lighting?                                           each item above, sums insured should represent the full
        If ‘YES’, give details                                                                              value of the property insured.
        _______________________________________________________
        _______________________________________________________                                 Note 2:     Professional fees necessarily incurred in reinstating
                                                                                                            buildings and machinery are automatically insured, provided
                                                                                                            sufficient allowance is made in fixing the sums insured on
 C      OCCUPANCY                                                                                           buildings and machinery respectively.
        To what extent will your premises be left unoccupied?
        by day                                                                                  Note 3:     Fire Brigade charges automatically included up to a limit of
        by night                                                                                            €6,500.


 D      SECURITY (When your premises are closed to customers and
        callers, or are left unoccupied)                      YES               NO

        (i) Are all external doors, windows and other
            openings secured?

        (ii) Do you have an intruder alarm?
             (if yes please forward a copy of alarm spec.)

        (iii) Was it installed by an NSAI registered alarm company?
            Name of company ____________________________

        (iv) Is it connected to a central station?




1B          Additional Covers                                                              Please tick if required.


 STEALING                                                                                                                                                 YES       NO
Covers loss or damage as a result of forcible and violent entry or exit. Sums insured as per section 1A
      Section 1                                                                                           Material Damage (continued)

 MONEY AND ASSAULT                                                                                                                                         YES     NO
Covers loss of money by any cause whatsoever and compensation for death or injury following assault of any person in charge of money or stock.
DO YOU REQUIRE COVER. IF ‘YES’ PLEASE ANSWER THE FOLLOWING QUESTIONS:

 1      What limit of indemnity do you require in respect of money comprising                   Standard Cover, capital €13000, Weekly €130.
        cash, cheques and other negotiable instruments (excluding crossed                       If ‘YES’, give details:
        cheques and other non-negotiable money)?
                                                                                                ________________________________________________________
                                                             Limits of indemnity
                                                                                                ________________________________________________________
        (a) In the premises out of business hours secured      €                                ________________________________________________________
            in a locked safe or strongroom.
            (standard cover €6,500)                                                             ________________________________________________________
                                                                                                ________________________________________________________
        (b) In the bank night safes until at bank’s risk.      €
            (standard cover €26,000)                                                            ________________________________________________________

        (c) Any other loss including whilst in transit or      €
            whilst in the premises during business hours.                                  4    Please complete details of safe(s) below:
            (standard cover €13,000)
(d)     In the custody of the Petrol Pump                      €                                  Make/Model       Dimensions      How anchored            Limit
        attendants/shop assistants between the
        hours of 8.00pm and 8.00am
             (maximum available limit €500)

 2      What is the estimated annual amount of lodgements
        and withdrawals of such money carried between     €
        premises and the bank?
 3      Do you wish to increase the level of benefit for assault?       YES    NO



     ACCIDENTAL DAMAGE TO MACHINES                                                                                                                         YES     NO
Covers loss or damage by fire, theft or accidental external means, of selected machines or equipment elsewhere than at the Premises.

                                  DESCRIPTION OF MACHINES OR EQUIPMENT                                                                SUMS INSURED

      Item 1

      Item 2




     COMPUTERS                                                                                                                                             YES     NO
Covers accidental loss or damage to computers, Re-instatement of Data of I.C.O.W.
 1      Computer(s) details, (if laptop please advise).

      NAME OF MANUFACTURER                            TYPE/MODEL NO.                             YEAR OF MAKE                     NEW REPLACEMENT VALUE




 2      Are your computers subject to a maintenance contract            YES    NO

        providing for free parts and free labour in the event of a

        breakdown?




 FROZEN FOODS                                                        (This section relates to Freezer Cabinets only).

Is this section required?                                               YES    NO
                                                                                         SUM INSURED (max. value of stock)                             €
Covers deterioration of frozen foods resulting from
(a) breakdown of refrigeration plant due to its own inherent defect.                       1                                                               YES     NO
                                                                                                Is there a current manufacturer’s guarantee warranty
(b) accidental failure of public supply of electricity and
                                                                                                on the plant
(c) escape of refrigerant or fumes.
Description of Plant and makers number;                                                    2                                                               YES     NO
                                                                                                Is there a current maintenance contract on the plant
_____________________________________________________________                                   and will this be kept in force
Makers name & date of manufacture

_____________________________________________________________
     Section 2                                                                                                            Business Interruption
 1     Is this section required?                                        YES   NO       the following
                                                                                       extensions at no extra charge.
       This section covers loss of profit through interruption
       of the business following any of the perils selected under                      •       Supplier’s extension
       the Material Damage section 1A - and Stealing                                   •       Customer’s extension
       if included.                                                                    •       Contract sites
       Gross Profit (including 100% of Payroll)                €
                                                                                       •       Prevention of access
       Increase in cost of working                              €                      •       Public utilities
                                                                                       •       Loss of attraction.
       Tax relief                                               €                      If a higher limit is required, please advise details.

       Rent Receivable                                          €

       Book debts                                               €

                                                                €
     __________________________________________
The Policy provides cover up to €13,000 for each of



Period for which indemnity is required: ________________________ consecutive months following the date of the damage. (If longer than 12 months then
sums insured should be adequate to cater for the period selected).

     Section 3                                                                                                                                        Liabilities

                            YES   NO                                           YES   NO                                                                          YES      NO

Is this section required?                          EMPLOYER’S LIABILITY                                      PUBLIC LIABILITY/PRODUCTS LIABILITY
                                                   Standard limit of                                         (Defective Workmanship/Sale of Goods)
                                                   indemnity €13 million.                                    Standard limit of indemnity €2.6 million.




 1     Describe precisely:
       (a) Work undertaken at your premises
       (b) Work undertaken away from your premises
       (c) Goods supplied, installed, erected, repaired, altered or
           treated by you.


 2                                                                      YES NO
       Have you entered into any agreement assuming a liability
       for injury, illness, loss or damage for which you would not
       have been liable in the absence of such an agreement?
       If ‘YES’, please supply a copy of the agreement.

 3     Do you use Sub-Contractors?
       If so give details.

 4     How do you ensure that any sub-contractors employed by you
       maintain adequate liability insurance?

 5     Do you import or export any goods
       If ‘YES’, give full particulars including countries concerned.

 6     Do you undertake operations outside the Republic of
       Ireland, Great Britain, Northern Ireland, the Channel
       Islands or the Isle of Man? if ‘YES’, give full particulars,
       including countries concerned, nature of activity, wages
       and expenditure.

 7     Do any of your activities involve exposure to noise levels
       exceeding 85-dB (A)? If ‘YES’, give full particulars.

 8     Are any of the following used in your business?
       if ‘YES’, please give details.
                                                                                     (a)
       (a) asbestos, silica or other substance involving a health hazard.
                                                                                     (b)
       (b) radioactive substances or other sources of ionising radiations.
                                                                                     (e)
       (c) flame cutting or welding plant or other heat producing plant
           or processes AWAY from your own premises.
                                                                                     If not, you should do so immediately in the interest of safety and to avoid prosecution. To
 9     Have you prepared a written safety statement in                  YES   NO
                                                                                     assist you, the information booklet “Guidelines on Safety Statements” is obtainable from
       accordance with the Safety, Health and Welfare at Work                        any office of the Health and Safety Authority. Our Risk Management services unit can
       Act 1989 and Safety, Health and Welfare at Work                               advise you on the preparation of a Safety Statement and the implementation of a safety
       General Application Regulations 1993?                                         policy. The Health and Safety Authority also provide guidance publications on safety
                                                                                     statements.
     Section 3                                                                                                         Liabilities (continued)
 PUBLIC/PRODUCTS LIABILITY
 1    Please state your projected turnover figures, which are to be inclusive of V.A.T., for the next 12 months under the following headings:

                                                 Cars/Light                       Heavy                             Buses/                           Others
                                                Commercials                     Commercials                        Coaches                          (specify)
 Sales of new vehicles                    €                                 €                              €                                  €
 Sales of used vehicles                   €                                 €                              €                                  €
 Servicing/Maintenance/Repair             €                                 €                              €                                  €
 Sale of spare parts/accessories          €                                 €                              €                                  €
 Petrol Sales                             €                                 €                              €                                  €
 Tyre Fitting/Sales                       €                                 €                              €                                  €
 Lease Hire Activity                      €                                 €                              €                                  €
 All Others – Specify below               €                                 €                              €                                  €
                                          €                                 €                              €                                  €
                                          €                                 €                              €                                  €



 2     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 forecourt? If YES please state such other purposes




 4    If you have Inspection Pits, are they guarded/closed over when not in use?




 5      If you have car wash facilities please state number of bays/booths


 6    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?
            (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.




 EMPLOYER’S LIABILTY
“Employee”, is deemed to include:- any director, executive director or partner of the insured engaged in the business; a member of the insured’s family engaged
in the business; any person employed by the insured under a contract of service or apprenticeship; labour masters and persons supplied by them; persons
employed by labour only sub-contractors; self-employed persons; drivers and/or operators of plant hired to the insured; persons gaining work experience; any
other person hired or borrowed by the insured. The total remuneration of the above must be included.

“Remuneration” means:- Gross wages, salaries, commission or fees including overtime, bonuses and all prerequisites and benefit-in-kind (but not employer’s
PRSI contributions), board and/or lodging, housing accommodation, housing subsidy, company car, employer’s contribution to pension or similar fund and
employer’s contribution to any insurance schemes arranged for the benefit of employees.

Gross wages etc. should include:- Employee’s contribution to PRSI, Employee’s contribution to pension or similar funds or insurance schemes and PAYE tax.
Turnover means gross turnover without any deduction and inclusive of Value Added Tax. Full contract price must be included without any deduction.
 EMPLOYER’S LIABILTY CONTD
Please state the numbers of persons employed and their estimated annual wages, salaries and all other earnings for the next 12 months under the following
headings. The figure should include a minimum of €21,000 for each full time employee.

                                   Description                              No. Part/Time                        No. Full/Time                       Estimated Annual
                                                                                                                                                     Remuneration
     Employees                     Clerical/Sales                                                                                                    €
                                   Mechanics – LCV’s                                                                                                 €
                                   Mechanics – HGV’s                                                                                                 €
                                   Shop Assistants                                                                                                   €
                                   Petrol Pump Attendants                                                                                            €
                                   Property repairs                                                                                                  €
     Partners                      Clerical/Sales                                                                                                    €
     /Directors
                                   Mechanics                                                                                                         €
     Others                                                                                                                                          €




     Section 4                                                                                                            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 unless specified by the Company. l Vehicles belonging to employees. l Vehicles in which a partner or director or an
employee is interested under a hire purchase agreement unless specified by the Company. l Any other vehicle used other than for Motor Trade
purposes.
                                                                                                                                                                            YES      NO
 1     Are you insured or have you ever been insured in respect of any motor vehicle including motor vehicle road risk?
       If Yes, please state the name of every insurer concerned




 2     Are you entitled to a No Claims Discount from your previous insurers in respect of any of the covers now proposed for?
       If Yes;             (a) Please state number of years.
                           (b) Please provide proof.

 3     Full particulars of all purposes for which the vehicle(s) will be used.




 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) Motor Cycles

 5     Description of all other vehicles (i.e. Breakdown/Own Goods Carrying vehicles/Motor Cycles) 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

 6     Are you an accredited Recovery Agent for any Motoring Organisation?
                                                                                              Number
       If YES any vehicle available for such recovery service must be included              of Recovery
                                                                                              Vehicles

 7     State scope of cover required under this section i.e.,
       “Comprehensive” or “Third Party, Fire & Theft” or “Third Party Only”
     Section 4                                                                                                                                                             Motor Road Risk Liability (continued)

8     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

                                                                                                                                Has any Driver a prosecution pending or
             Name of Driver        Type of licence currently held and   Description   Age                Occupation               any Penalty Points imposed on their             Record of        Have any insurers ever          Has he/she defective
                                            Country of Issue            of use Code               (If not employed in the        licence or ever been convicted of any        Accidents/Claims      refused or cancelled or         vision or hearing or
                                      (e.g. Full, Provisional etc.)        (A), (B)             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
                                                                            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
                                                                                                                                                                            Number       Cost


1                                                                                                                                                                                    €

2                                                                                                                                                                                    €

3                                                                                                                                                                                    €

4                                                                                                                                                                                    €

5                                                                                                                                                                                    €

6                                                                                                                                                                                    €

7                                                                                                                                                                                    €

8                                                                                                                                                                                    €

9                                                                                                                                                                                    €

10                                                                                                                                                                                   €

11                                                                                                                                                                                   €

12                                                                                                                                                                                   €

13                                                                                                                                                                                   €

14                                                                                                                                                                                   €

15                                                                                                                                                                                   €

16                                                                                                                                                                                   €

17                                                                                                                                                                                   €

18                                                                                                                                                                                   €

19                                                                                                                                                                                   €

20                                                                                                                                                                                   €
    Section 5                                                                                                          Personal Accident
                                                                                          YES     NO
     Is this section required?                                                                                           Further Details
     (All your employees must be covered if section required)

1    To your best knowledge and belief is each person to be insured in good health
     and free from physical and mental defect? If ‘NO’ please give details

2    Will persons to be insured travel overseas on your business?
     If ‘YES’ pelase give details of countries likely to be visited

3    Please give details of all injuries and serious illnesses suffered by any person to be
     insured during the last 5 years:

     _________________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________________


     ESTIMATED NUMBER OF PERSONS TO BE INSURED


     Description                                                                      Estimated No.

     Managerial sales and clerical employees not working
     manually in the business

     All other employees


     COVER & BENEFITS

1    Cover required                                         24 Hour accident
     (Tick as appropriate)


2    Benefits (if higher limits required, please specify)

                                          (A) Capital Sums:                    Death___________________________________________

                                                                               Loss of limb(s) or eye(s) ____________________________

                                                                               Permanent total disablement ________________________

                                          (b) Capital Sums                     Temporary total disablement _________________________
     General Questions
                                                                             PLEASE ANSWER FULLY
                                                                                                    YES    NO
 1    Have you or any principal in the business or any company in which you have had                                                           DETAILS
      an interest been declared bankrupt, the subject of bankruptcy proceeding or
      made any agreement with creditors? If “YES”, give details.
                                                                                                     YEARS
 2    How long have you been established at these premises?
      If less than 3 years, please provide previous business history.
                                                                                                    YES    NO
 3    Are you an NSAI registered firm? if “YES”, give details.
                                                                                                                         CLASS OF INSURANCE                     INSURER
 4    Are you at present insured or have you ever proposed for insurance in respect of
      any of the perils or contingencies to which this proposal applies? If “YES”, give details.

 5    To the best of your knowledge and belief have you or any other person(s) material
      to this risk

      a)     been convicted of any offence of any nature or is any prosecution pending
             or been disqualified from driving?

      b)     been refused any insurance, renewal or had any special terms or conditions’
             imposed by an insurer? If “YES” to either a) or b) please give details

      c)     been involved in any accident or loss or have any claims been made against
             you or them in the past five years? If “YES” please insert details below.


(a) Motor                                                         Previous Claims/Accident History

                                                                     Total cost of settled claims                                          Claims not yet settled
           Year             Total number of
                          accident and losses                Damage to                          Third party                  Damage to                              Third party
                                                          proposers vehicles                      claims                  proposers vehicles                          claims
                                                      No.         Amount               No.            Amount          No.          Amount                 No.              Amount




(b) Liability
                                                                           Employers Liability Claims            Public Piability Claims                 Products Liability Claims
           Year           Total remuneration to         Gross
                           employees and ther          turnover      No.        Paid         Outstanding   No.      Paid        Outstanding        No.       Paid          Outstanding
                                  person                                         €               €                   €               €                          €              €




(c) Material Damage plus all other covers being proposed for insurance

                  No.                        Type of claim                       Amount paid                      Amount outstanding                            Date of loss
  Additional Information (if any)




  Declaration

IMPORTANT - Any other facts known to you, which are likely to affect acceptance or assessment of the risks proposed for insurance, must be disclosed. Should
you have any doubt about what you should disclose, do not hesitate to tell us, or your insurance advisor. This is for your own protection, as failure to disclose
may mean that your policy will not provide you with the cover you require, or may invalidate the policy altogether.

WARNING: As it is an offence under the Road Traffic Act to make any false statement or withhold any material information for the purpose of obtaining a Certificate of
Insurance, great care should be taken to ensure that all questions and sub-sections of questions are answered fully and accurately. If the proposer is a firm or private company,
the questions are to be read and answered as also applying to each individual partner or member.

The Third EU Non-life Directive requires us to provide you with the following information prior to purchase:

THE LAW APPLICABLE TO THE CONTRACT - Under the relevant European and Irish legal provisions, the parties to the proposed contract of insurance, we, Hibernian
General Insurance Limited and you, the Proposer, are free to choose the law applicable to the contract. We propose that Irish law will apply to the contract. The Insurer with
which your contract will be concluded is Hibernian General Insurance Limited, which is established in Ireland.

COMPLAINTS PROCEDURE - If you have any complaint about the insurance contract, you should contact either the insurance agent or broker who arranged the policy for
you, or the branch of Hibernian that issued the policy. If your complaint is not resolved to your satisfaction, please write to the Managing Director, Hibernian General Insurance
Limited, Haddington Road, Dublin 4.

If you are still dissatisfied, you may contact:
    a) the Insurance Federation’s Insurance Information Service at 39 Molesworth Street, Dublin 2 (Telephone: 01 676 1914 or Fax: 01 676 1943, Email: fed@iif.ie,
       Website: www.iif.ie). The service can advise you on how to proceed further, and may be able to help in resolving the problem.
    b) the Insurance Ombudsman of Ireland (if you are a personal policyholder) at 32 Upper Merrion Street, Dublin 2 (Telephone 01 662 0899 or Fax: 01 662 0890,
       Email: enquiries@ombudsman-insurance.ie, Website: www.ombudsman-insurance.ie).
Taking any of these options will not prejudice your right to take legal action.

DATA PROTECTION - The information you provide about yourself and about third parties will remain confidential and may be used for the provision and administration of
insurance products and related services. Such information may be disclosed in confidence for these purposes to agents or service providers appointed by Hibernian, regulatory
bodies, other insurance companies (directly or via a central register) and other Aviva group companies. This information will be processed and held on our computer and
manual record systems.
A person may request, in writing, a copy of details about himself/herself held by Hibernian by sending a written request to the Data Protection Compliance Officer, Hibernian
General Insurance Ltd, Haddington Road, Dublin 4 together with payment of the applicable fee (currently €5.00). There is also a right to correct any inaccuracies identified in
the personal data we hold.

IMPORTANT NOTE - Some of the questions in this form request details about health and any convictions. This information forms an important part of the underwriting
process. By signing below you are giving your explicit permission for the processing of these details for the above purposes, including, where deemed appropriate, liasing with
third parties to verify the accuracy or completeness of data. You confirm by signing below that you have fully explained to each person for whom insurance cover is sought,
the purposes and use for which that information has been obtained and how the information may be used, in the same detail as set out in this form and that each person has
explicitly consented to such. IT IS YOUR SOLE RESPONSIBILITY TO ENSURE THAT YOU HAVE FULLY UNDERSTOOD AND COMPLIED WITH THESE REQUIREMENTS
BEFORE SIGNING THIS DECLARATION.

DECLARATION - I/We declare that the statements and particulars given in this proposal are, to the best of my/our knowledge and belief, true and complete and that this
proposal will form the basis of my/our contract with Hibernian General Insurance Limited. I/We confirm that I/We am/are giving my/our permission for the information provided
in this form to be used for the purposes set out in the Data Protection section above.


Signature:                     ____________________________________________________                                     Date: ______________________________

Please note that the details you are being asked to supply may be used to provide you with information about other products and services either from Hibernian or other Aviva
group companies or which any member of the Aviva group has arranged for you with a third party.
The fact that you choose not to receive such information will not affect any aspect of the facilities that we provide to you now or in the future.
Please tick here       if you do not wish this information to be utilised for this purpose.
     We are part of the Hibernian Group, one of Ireland’s largest and most
     successful financial organisations. We are backed by the strength of Aviva plc,
     one of the world’s largest insurance organisations, which operates in over 50
     countries worldwide.

     We are very proud of our strong reputation in Ireland. Our activities include
     general insurance, managing risk, pensions and life assurance, managing
     investments and personal financial services. Our aim is to provide an efficient
     and professional service through our nationwide network of branches and
     independent brokers, together with our customer contact centre and website.

     Good thinking is at the heart of everything we do. From our intelligent, original
     products and services to our commitment to security, quality and value, we are
     constantly thinking of new ways to meet our customers’ needs today,
     tomorrow and in the future.

     So whenever you think ahead, think Hibernian.




                             For our joint protection, we may record and
                                         monitor phone calls.

                       Willis Risk Services (Ireland) Limited (t/a Willis) is regulated by the Financial Regulator




                                                                                                                              PF/030/07/06




                                            Hibernian General Insurance Limited
                       Phone: 01 607 8000 Email: info@hibernian.ie Website: www.hibernian.ie
                      Registered in Ireland No 3319 Registered Office: Haddington Road, Dublin 4
Hibernian General Insurance Limited is regulated by the Financial Regulator and is member of the Irish Insurance Federation

				
DOCUMENT INFO