Motor Proposal Form 1) GENERAL (a) Full name of proposer (b) Date of birth Postal Address Street Address Address Line 2 City (e) Contact Tel No Email Address* Period of insurance From To 2) DETAILS OF PROPOSER a)Are you fully licenced for this class of vehicle Yes No b)Date when licenced c)If not licenced who will be driving the vehicle d)Details of relationship and licence details e)Do you or any person who to your knowledge will drive your car suffer from any physical disability or infirmity? Yes/No. Give details f)Have you or any person who to your knowledge will drive your car ever been convicted of any motoring offence? Give details 3) Details of any accidents, losses or claims during the past 3 years Month/Date of loss: Amount Paid/outstanding: Month/Date of loss: Amount Paid/outstanding: 4) VEHICLE DETAILS MAKE/MODEL REG. # Engine # Chassis # Year of make Estimated Value Accessories Value of Accessories 5. Provide any other material information that could be helpful in understanding your vehicle and its driver (s) 6. What is the vehicle used for Declaration I/We hereby declare that the above particulars and statements are true, correct and complete and contain all information known to me/us affecting the risk to be insured, and that this and any other written statement made by me/us or on my/our behalf for the purpose of insurance shall be the basis of and incorporated in the contract between me/us and Champions Insurance Company as CIC, (hereinafter called the Company) shall be promissory I/We further agree to accept insurance on terms and conditions set forth in the Company’s policy, and particularly undertake to notify the company immediately of any alteration in the risk. We further agree that liability shall attach to the Company from the date of receipt of the premium payment. Agent Agency No WARNING: INSURANCE FRAUD IS A CRIME I hereby certify that the information in this application form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to furnish me with a quotation based on the information provided.