Additional Vehicle Form Order Number Policyholder Name Policy Number Contact Number * Email Subject to the terms and conditions of the policy, please add/substitute the vehicle described in the particulars. * Add Substitute Particulars of the motor car(s) to be insured Number of vehicles to be insured 1 - one 2 - two First vehicle License Reg No. Make Type of Body Horse Power or Cubic Capacity Year of Manufacture Seating Capacity (incl Driver) Date Purchased Market Value (incl Accessories) Engine No. Chassis No. All Questions must be answered fully Will anyone be driving the vehicle have less than two years driving experience? * Yes No Will anyone under 25 years be regularly driving this vehicle? * Yes No Is this vehicle purchased under a Hire Purchase Agreement? * Yes No Address at which the vehicle is usually garaged * Has this vehicle ever been involved in an accident? * Yes No Have you or has anyone who will drive your motor vehicle, ever had any accidents or made any claims with this or any other motor vehicle? * Yes No Is your vehicle fitted with an anti-theft device? * Yes No Cover Required Comprehensive Hurricane cover Windscreen cover Third Party Fire & Theft Third Party only Effective date of cover Declaration: I/We warrant that the above Statement and Particulars which I/we have read over and checked are true. I/We have not suppressed or misstated any material fact and that the Vehicle (or Vehicles) above referred to is/are in good condition and repair. I/We agree that this declaration in conjunction with the original Proposal shall form the basis of the Contract between me/us and the Company and will be deemed as incorporated in the Policy. (Privacy Policy) * Date of Declaration Name of Insured
