Motor Quote

Your Personal Details

Title

Forenames

Surname

How long have you held a licence?	Type of current licence

Country of Issue

House name or number

Street

Telephone Number

Date of birth (dd/mm/yy)

Occupation/profession

Do you or does any person who to your knowledge will drive have (or have any history of) defective vision or hearing (not corrected by glasses or hearing aid), diabetes or any disease or physical or mental infirmity or fits of any kind?

Yes No

If "yes", give details

Loyalty Discount

We offer a premium discount of 10% for every additional motor or home insurance policy taken out with Argus. If you are already an Argus policyholder, please provide details (policy number)

Vehicle

Make

Model

Registration mark	Country of registration	cc of engine

Year of make	Estimated value (£)	Seating capacity

Have any changes been made to the maker's specifications?	Yes No	If "yes", give details
Is the vehicle usually kept at the above address?	Yes No	If "no", state address
Are you the owner of the vehicle and is it registered in your name?	Yes No	If "no", give reason for vehicle being insured in your name and state name of owner
Alarm/Immobiliser/Tracker	Yes No

Use

In addition to social, domestic and pleasure use (which includes travel to and from your normal place of work and business use by you and your spouse) will the vehicle be used for:
Business purposes by any other persons?	Yes No
Commercial travelling, professional driving tuition or trade purposes?	Yes No

No Claim Discount

Are you, or have you been insured in your own name in respect of any motor vehicle (apart from any Cover Note issued with this proposal)?	Yes No
No Claim Discount
If you have, or have previously had motor insurance with Argus please state policy number
Do you want to protect your no claims bonus if you make a claim? (At an additional cost)	Yes No

Comprehensive Cover

	Hour	Minute	Date (dd/mm/yy):
Cover to commence	:

Do you wish to restrict driving to one driver only?	Yes No
Give details below of yourself and all other persons who to your knowledge will drive.

Names of drivers	Date of birth (dd/mm/yy)	Occupation	Period of Driving	Type of current licence




(If you or any driver are over 70 years please supply copy of licence and/or medical certificate)

Have you or any person who may drive had any claims accidents, damage fire or theft losses during the past 5 years?	Yes No	If "yes", give details and indicate driver involved
Is any driver aged under 30 years?	Yes No	If "yes", complete a. b. and c. below
a. Does he/she own a vehicle insured separately?	Yes No	If "yes", state name of insurer
b. Is he/she the Main User of the vehicle proposed?	Yes No
c. How many cars are owned or used by you and members of your household, including company cars?
Have you or any person who to your knowledge will drive:
a. ever been disqualified from driving?	Yes No	If "yes", to a. to f. give full details: eg. convictions endorsement offence code, date, fine and period of disqualifications (if any)
b. been convicted during the past 5 years of any offence in connection with any motor vehicle?	Yes No
c. any prosecution or police enquiry pending?	Yes No
d. had a proposal declined	Yes No
e. been required to pay an increase premium or had special terms imposed?	Yes No
f. had a policy cancelled or been refused renewal?	Yes No

Declaration

I/We hereby declare that to the best of my/our knowledge and belief the above statements and particulars are true and correct and that I/we have not withheld any information material to the Proposal whether the subject of a proposal form question or not. I/We agree to accept and conform to the terms of the policy when issued. I/We undertake that the vehicles to be insured shall not by driven by any person who to my/our knowledge has been refused Motor Vehicle Insurance or continuance thereof.

Important

All material facts must be disclosed. Failure to do so could invalidate the policy. A material fact is one likely to influence an Insurer in the assessment and acceptance of the proposal (e.g. any criminal conviction concerning dishonesty). If you are in any doubt as to whether a fact is material then it should be disclosed to the Insurer.

Complaints Procedure

Our aim is at all times to provide a first class service. However, there may be occasions when you feel that this objective has not been achieved. Should you have any query or complaint regarding this insurance please contact either your local adviser or write to the Argus Insurance Company (Europe) Limited, Regal House, 3 Queensway, Gibraltar.

Argus Insurance fully complies with the FSC regulations in respect of the Distance Marketing Act 2006. For full details of this, please visit www.fsc.gi.
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