Insurance Personal Lines | Insurance Commercial Lines
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To be completed by the Insurance Agent
Please fax pages 1 to 4 to us as soon as possible on 0845 122 3010
Agent’s name Ageas agency number
Agent’s reference (if any) Quote Reference (if any)
Premium Contract type Standard n Economy n Introductory discount? YES n No n
Insurance required from Date Time
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
Do you own your own home? YES n No n
Post code of where vehicle kept if different
2. Car details
Make & model (state if GL, GTI etc.)
Right hand Engine Purchase Estimated Est. annual Current No. of Year of Registration
drive? capacity date value mileage mileage seats make number
Do you own the car? YES n No n
If ‘No’ give details
Are you the registered keeper? YES n No n
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 YES n No n
had optional extras fitted?
If ‘Yes’ give details
Has the vehicle been fitted with an alarm, immobiliser or tracking device which is not fitted as standard? YES n No n
If ‘Yes’ give name of device including exact model
Where is the vehicle normally kept overnight when at the usual garaging address (e.g. Garage, Driveway, Public Road)?
Personal Lines | Commercial Lines | Protection
3. Cover required
Comprehensive YES n No n
Third Party Fire & Theft (car must be valued at under £4,000) YES n No n
Do you wish to pay the first part of any claim for damage to your vehicle? YES n No n
If ‘Yes’, indicate amount: £100 n £125 n £150 n £200 n £250 n £300 n
This will be in addition to any other amount we may require you to pay.
4. Use required (see below for details or ask your agent for advice)
Social, domestic & pleasure ex commuting n Social Domestic & pleasure inc commuting n Class one (You only) n
Class one (Spouse only) n Class one (You & your spouse) n Class one (You & civil partner) n
Class one (Civil partner only) n Class two n Class three n
5. Previous insurance details
Previous insurer Policy number Renewal date
Number of years No Claim Discount earned
If 4 years or more, do you wish to have your discount protected? YES n No n
Use required - See section 4 of the proposal Class 1 - Business use by the Policyholder and the
This is a description of the uses available in section 4. Policyholder’s Civil Partner
Please ensure you choose the correct option. If you need Use for social, domestic and pleasure purposes and by the
further help please ask your insurance adviser. Policyholder and (name of Civil Partner) each in person in
connection with their business or profession EXCLUDING
Social, Domestic & Pleasure excluding commuting use for commercial travelling, any purpose in connection with
Use for social, domestic and pleasure purposes. the motor trade or for hiring, racing, competitions, rallies or
EXCLUDING use for commuting, any business purposes, any trials.
purpose in connection with the motor trade or for hiring,
racing, competitions, rallies or trials. Class 1 - Business use by the Policyholder’s Civil Partner
Social, Domestic & Pleasure including commuting Use for social, domestic and pleasure purposes and by
Use for social, domestic and pleasure purposes. (name of Civil Partner) in person in connection with his/her
EXCLUDING use for any business purposes, any purpose in business or profession. EXCLUDING use for commercial
connection with the motor trade or for hiring, racing, travelling, any purpose in connection with the motor trade or
competitions, rallies or trials. for hiring, racing, competitions, rallies or trials.
Class 1 – Business use by the Policyholder only Class 2 – Use on the Policyholder’s business only
Use for social, domestic and pleasure purposes and by the Use for social, domestic and pleasure purposes and for the
Policyholder in person in connection with his/her business or business of the Policyholder and the Policyholder’s employer.
profession. EXCLUDING use for commercial travelling, any EXCLUDING use for commercial travelling, any purpose in
purpose in connection with the motor trade or for hiring, connection with the motor trade or for hiring, racing,
racing, competitions, rallies or trials. competitions, rallies or trials.
Class 1 – Business use by the Policyholder’s spouse only Class 3 – Use for commercial travelling on the Policyholder’s
Use for social, domestic and pleasure purposes and by the business only
Policyholder’s spouse in person in connection with his/her Use for social, domestic and pleasure purposes and for the
business or profession. EXCLUDING use for commercial Policyholder’s business. EXCLUDING use for hiring, racing,
travelling, any purpose in connection with the motor trade or competitions, rallies or trials.
for hiring, racing, competitions, rallies or trials.
Exclusion: THIS APPLIES To ALL CLASSES oF USE
Class 1 – Business use by the Policyholder and the Use to secure the release of a motor car, other than the
Policyholder’s spouse only vehicle identified above by its registration mark, which has
Use for social, domestic and pleasure purposes and by the been seized by, or on behalf of, any government or public
Policyholder and the Policyholder’s spouse each in person in authority is excluded.
connection with their business or profession. EXCLUDING
use for commercial travelling, any purpose in connection with
the motor trade or for hiring, racing, competitions, rallies or
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6. Drivers required
You only YES n No n
You & the driver(s) named below YES n No n
The drivers named below and any other driver aged 36 years or over YES n No n
Please give details of yourself and all other drivers.
Drivers aged 35 or younger will NOT be covered unless their details are shown below.
Driver 1 (You) Driver 2 Driver 3 Driver 4
Driver’s name AS PREVIoUS
State MALE or FEMALE
Relationship to Driver 1 (you)
Date of Birth
occupation (Give full and part time occupations)
Type of licence held (e.g. Full UK car licence,
Provisional car licence)
Number of years licence held
Will the driver use the vehicle for commuting?
Is the driver the main user?
Has the driver been a regular driver in the U.K. for the past
Does the driver own any other vehicle?
Does the driver have use of any other vehicle?
Has any driver ever been refused insurance or had their
Has any 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 any driver been convicted of any motoring offence,
including fixed penalty offences, within the past 5 years?
If ‘YES’ please give details in 8 below.
Does any 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 Was the incident fault Was NCD affected?
or non-fault? (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 Is the DVLA aware
of this condition?
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Important notes: and prevent fraudulent claims. These include the Claims and
1. Your policy will be based on the information provided in Underwriting Exchange register, and the Motor Insurance
this proposal form. Anti-Fraud and Theft Register and the Motor Insurance
Database. We may pass information relating to your
2. Failure to disclose all material facts could render your insurance policy and any incident (such as an accident or
insurance invalid and not give protection in the event of a theft), to the operators of these registers. Under the
claim. Material facts are those which we would regard as conditions of your policy, you must tell us about any incident
likely to influence the acceptance and assessment of this (such as an accident or theft) which may or may not give rise
Proposal. If you are in any doubt about the facts to a claim. Data from the Motor Insurance Database (MID)
considered material, you should disclose them. We will be may be used to establish whether a driver is insured to drive
happy to give you advice if you wish. a vehicle and/or for preventing or detecting crime. If you are
involved in an accident in the UK or abroad, the MID may be
3. It is an offence under the Road Traffic Act to make a false searched to obtain relevant policy information. You can find
statement or withhold any material information for the out more at www.mib.org.uk. You should show this notice to
purposes of obtaining a Certificate of Motor Insurance. anyone insured to drive the car covered under the policy.
4. We recommend that you keep a copy of this Proposal and If premiums are paid by instalments, information may be
a record of all information (including copies of any letter shared with other companies through credit reference
or other documents) supplied to us. We will give you a agencies. Such information is used to make lending
photocopy of this Proposal if you ask us within 3 months decisions and, on occasion, to prevent fraud.
of the start of cover.
5. Cover will not start until an Ageas Certificate of Motor I/We declare that to the best of my/our knowledge and belief
Insurance or Cover Note is issued. the information I/we have given is true and complete.
6. Ageas reserves the right to decline this Proposal or to offer I/We understand that you will pass the information on this
a policy containing restrictions in cover. form and about any incident I/we may give details of to other
interested parties, so that they can make it available to other
7. Unless we agree otherwise, English law will apply to this insurers. I/we also understand that, in response to any
contract of insurance. searches you may make in connection with this application or
any incident I/we have given details of, information may be
8. A specimen of our current policy is available on request. passed to you which has been received from other insurers
about other incidents anyone insured to drive the vehicle
9. This is our standard client agreement upon which we covered under the policy have been involved in.
intend to rely. For your own benefit and protection you
should read these terms carefully before signing them. If I/We give consent for you to exchange information with the
you do not understand any point please ask for further Police where this is needed to validate a claim.
We may use information we hold about you to contact you
about Insurance. Information may be used by us, other
Signature of proposer
companies in the Ageas group and by our agents and service
partners acting under our instruction for the purpose of
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.
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
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Customer service Message relay
We do everything possible to ensure that all persons taking We can pass messages to friends, family or colleagues.
out Motor Guard are provided with the high standard of
service they would expect of us. In the event that you have Repair service
any cause for dissatisfaction in relation to your insurance If your car can be repaired, we will arrange for one of our
policy, please write to the customer service advisor at our approved repairers to contact you to arrange collection of
registered address. These procedures do not affect your your car in order that repairs may proceed.
• There is no need for you to get estimates.
• We will provide you with a small courtesy car with a
ONECALL - 0845 122 3018 manual gearbox while your car is being repaired.
Claims helpline open 24 hours a day, 365 days a year • Once your vehicle has been repaired, it will be delivered
onecall is a first-response service with operators that can back to you.
immediately confirm whether your policy covers you for an
incident. Broken windscreen and window glass
Ageas Glassline: 0800 174764
Should your car be involved in an accident, phone us directly
and we will validate your claim and discuss with you how
your claim will be progressed.
For Comprehensive Policyholders we provide:
If the car is not roadworthy after an accident, we can arrange
to get you and your passengers from the scene of the
accident to your home or to your planned destination.
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
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