Private Motor Proposal Form

1)General
2) DETAILS OF PROPOSER
 
3) VEHICLE DETAILS
Make/Model
Reg. #
Engine #
Chassis #
Year of Make
Market Value
Type Of Cover Required
Types of cover available includes comprehensive, Third Party, Third Party Fire and Theft Only

4)What is the vehicle used for

5)

6) Details of any accidents, losses or claims during the past 3 years

Optional extensions

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.

For official use