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					 Insurance Personal Lines | Insurance Commercial Lines




   Motor Guard
   Proposal Form
   MU07 Nov 2010


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 address

  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
  Full address
                                                                                                       Post code
  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
                                                                   only
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
trials.




2   MU07 Nov 2010
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
Marital Status
Relationship to Driver 1 (you)
Date of Birth
occupation (Give full and part time occupations)
Employer’s business
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
3 years?
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
policy cancelled?
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)




8. Convictions
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?




                                                                                                                MU07 Nov 2010    3
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.
                                                                   Declaration
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.
   information

Data protection
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
                                                                     Date
services to you.

We may share your personal information with operators of
registers used by the insurance industry to check information




4   MU07 Nov 2010
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.
legal rights.
                                                                 •	 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:
Get-you-home-service
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

    Office address
    Ageas House, The Square,
    Gloucester Business Park, Brockworth,
    Gloucester GL3 4AD

    Registered address
    Ageas House, Tollgate, Eastleigh,
    Hampshire So53 3YA

    Email: talkback@ageas.co.uk
    Website: www.ageas.co.uk

    Registered number 354568

    Ageas Insurance Limited is authorised
    and regulated by the Financial Services
    Authority




                                                                                                                MU07 Nov 2010    5

				
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