Private Motor
 
PLEASE GIVE A DEFINITE REPLY TO EACH QUESTION ON THE FORM

Note: It is an offence under the Road Traffic Act to make any false statement or withhold any material information to obtain a Certificate of Motor Insurance. The liability of the Insurers does not commence until the acceptance of the Proposal has been formally intimated by the Insurers.



Full Name


Occupation

Age


Will you be the primary driver?
Yes No


Vehicle: Year
Make
Model


Will there be any other drivers?
Yes No

Any loss or accidents within the past three (3) years?
Yes No

Are presently insured?
Yes No


Your contact Info:

Telephone





E-mail Address