Private Motor Proposal | Netherlands Insurance

COVER PROVIDED

The following alternative forms of cover are available (see Question 18):

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COMPREHENSIVE
- Liability for injury to third parties and damage to third party property and loss of or damage to the insured vehicle.
THIRD PARTY FIRE & THEFT
- Liability for injury to third parties and damage to third party property and loss of or damage to the insured vehicle by fire or theft.
THIRD PARTY ONLY
- Liability for injury to third parties and damage to third party property.

NETHERLANDS INSURANCE COMPANY (W.I.) LTD. NO CLAIM DISCOUNT SCALE

Your premium will be reduced by the amount specified in the No Claim Discount scale for each policy year provided no claim is made or arises prior to the renewal of the policy.

AFTER:

	PREMIUM DISCOUNT
INTRODUCTORY BONUS	25%
1 Year	30%
2 Years	35%
3 Years	40%
4 Years	45%
5 Years	50%
Over 5 Years	55%

Phone

EACH OF THESE QUESTIONS MUST BE ANSWERED COMPLETELY

Name of Proposer *

(in full)

Trade/Occupation/ Profession/Business *

Work *

Mobile *

Date of Birth *

Email *

Home

Other

How would you like to receive your documents? *

Email Post

Address *

Mailing Address

Town/Village *

Parish *

Do you have any other insurances with NETHERLANDS INSURANCE COMPANY (W.I.) LTD.? *

Yes No

Please give Particulars

How long have you and/or your driver held a valid drivers licence? *

To your knowledge, will anyone driving the motor vehicle:

Have less than two years regular driving experience? *

Yes No

Be less than 25 years of age? *

Yes No

Please give driver’s name

Please give driver’s age

Have you the Proposer ever suffered from defective vision, hearing, or any other physical disability or infirmity? *

Yes No

Please state nature of ailment

Will any other person who to your knowledge is likely to drive the motor vehicle ever suffered from the ailments in above *

Yes No

Please state nature of ailment

Have you ever been convicted of any offence in connection with the driving of any motor vehicle? *

Yes No

Please state the date and nature of conviction

Has anyone who will drive your motor vehicle been convicted of any offence in connection with the driving of any motor vehicle? *

Yes No

Please state the date and nature of conviction

Are you now or have you ever insured a motor vehicle in your name? *

Yes No

Please state name of Company/Companies

Has any Insurance Company ever declined your proposal? *

Yes No

Please explain

Has any Insurance Company ever increased your premium? *

Yes No

Please explain

Has any Insurance Company ever required you to carry/pay the first portion of any loss? *

Yes No

Please explain

Has any Insurance Company ever refused to renew or cancelled your policy? *

Yes No

Please explain

Has any Insurance Company ever intimated they would prefer you to place the business elsewhere or otherwise hinted or informed You that they do not wish to continue your insurance? *

Yes No

Please explain

Have you or has anyone who will drive your motor vehicle, ever had any accidents or made any claims (including Windscreen Damage) with this or any other motor vehicle? *

Yes No

Please give details

Give a separate answer for each year: (Year, Number of Vehicles, Number of Claims or Accidents, Accidental Damage, Third Party, Outstanding)

Will the motor vehicle be kept secured on your premises at night in a locked garage or driveway? *

Yes No

Where the motor vehicle is to be kept at night

How many vehicles are kept on the same premises?

Has the motor vehicle been modified in any way or fitted with oversized tyres or a high performance engine or equipment? *

Yes No

Please give details

Is your motor vehicle:

new/second-hand

New Second-hand

left/right hand drive

Left-hand drive Right-hand drive

Registered in your name? *

Yes No

Subject to a Hire Purchase or Mortgage Agreement? *

Yes No

Please state the name and address of the Finance Company

Has the motor vehicle ever been involved in an accident? *

Yes No

Please give details

Is your motor vehicle fitted with an anti-theft device? *

Yes No

Please give details

Will your motor vehicle be used for any purpose in connection with

The Motor Trade? *

Yes No

Please give details

Racing, pacemaking, speedtesting? *

Yes No

Please give details

Will your motor vehicle be used only for private and domestic purposes or travelling to and from your place of business? *

Yes No

Please state other use

Is your motor vehicle in good condition and repair and will it be kept so? *

Yes No

Type of cover required is *

COMPREHENSIVE THIRD PARTY FIRE AND THEFT THIRD PARTY ONLY

Do you wish to extend the Policy to include WINDSCREEN DAMAGE? *

Yes No

Do you wish to extend the Policy to include loss or damage and/or liability arising from flood, hurricane, windstorm, tornado, earthquake, volcanic eruption, or any other convulsion of nature? *

Yes No

Risk date from *

To *

PARTICULARS OF THE MOTOR VEHICLE TO BE INSURED

License Registration No *

Type of Body *

Year of Manufacture *

Date Purchased *

Engine No. *

Make *

Horse Power or Cubic Capacity *

Seating Capacity (incl. Driver) *

Market Value Incl. Accessories *

Chassis No. *

NOTE: YOU ARE REQUIRED TO ENSURE THAT THE SUM INSURED IS REVISED EACH YEAR TO REFLECT THE CURRENT MARKET VALUE. CLAIMS WILL BE SETTLED ON AN INDEMNITY BASIS – FOR TOTAL LOSSES YOU WILL BE PAID THE ASSESSED PRE-ACCIDENT VALUE, PROVIDED THE SUM INSURED IS ADEQUATE.

I/We Warrant the above statements and particulars which I/We have read over and checked are true, and that the motor vehicle(s) referred to is/are in good condition and repair. I/We desire to effect an insurance with NETHERLANDS INSURANCE COMPANY (W.I.) LIMITED subject to the terms, conditions and exceptions of the Policy to be issued by the Company. I/We agree that this Proposal shall form the basis of the Contract between me/us and the Company, and shall be deemed to be incorporated in the Policy to be issued.

Proposer's Name *

Date

NOTE: POLICIES ARE ISSUED ON A ‘NAMED DRIVER’ BASIS WITH COVERAGE BEING AFFORDED TO THE PERSON NAMED IN THE PROPOSAL ONLY. A COMPLETED “NAMED DRIVER” FORM IS REQUIRED FOR EACH ADDITIONAL NAMED DRIVER.

I/We understand that the Policy is on a “Named Driver” basis and that no cover is afforded if my/our motor vehicle is operated by any person not named as a driver and that a completed “Named Driver” Form is required for each additional named driver.

Proposer's Name *

Date

COVER PROVIDED

EACH OF THESE QUESTIONS MUST BE ANSWERED COMPLETELY

PARTICULARS OF THE MOTOR VEHICLE TO BE INSURED

NOTE: YOU ARE REQUIRED TO ENSURE THAT THE SUM INSURED IS REVISED EACH YEAR TO REFLECT THE CURRENT MARKET VALUE. CLAIMS WILL BE SETTLED ON AN INDEMNITY BASIS – FOR TOTAL LOSSES YOU WILL BE PAID THE ASSESSED PRE-ACCIDENT VALUE, PROVIDED THE SUM INSURED IS ADEQUATE.

NOTE: POLICIES ARE ISSUED ON A ‘NAMED DRIVER’ BASIS WITH COVERAGE BEING AFFORDED TO THE PERSON NAMED IN THE PROPOSAL ONLY. A COMPLETED “NAMED DRIVER” FORM IS REQUIRED FOR EACH ADDITIONAL NAMED DRIVER.

Netherlands Insurance

Frequently Asked Questions

Netherlands in Antigua

Office Hours – Grenada

Office Hours – Antigua