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Motor Proposal Form

Step 1 of 7 - PROPOSER`S DECLARATION

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Proposer's Declaration*
I declare that the information to be provided by me is to the best of my knowledge, true, and that I will not withhold or misrepresent any information concerning the assessment of the risk, and that the vehicle/property referred to is in good condition.
I agree that this proposal and declaration shall form the basis of the contract between me and Gulf Insurance Limited and shall be deemed to be incorporated in the Policy to be issued.
I agree that any breach of this declaration, shall render the insurance cover void from inception.

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PROPOSER DETAILS
Are you an individual or a company?*
Are you currently a policyholder?*
- Yes
- No
Has a quote been completed?*
- Yes
- No
Kindly indicate the quote number*
Only numeric values are allowed. Max length 20 digits
Kindly indicate the quote number
Please enter a number greater than or equal to 0.
Will this be a joint policy?*
- Yes
- No
Policyholder Details
Salutation
Last Name*
First Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
AGE
Driver's License date of inception*
Date Format: DD slash MM slash YYYY
DRIVER LICENSE
Gender*
Occupation*
Company Name*
Nature of Business
Address 1
Address 2
Town/City*
Country*
Contact No.
Email*
Are you a resident or citizen?*
Of which country are you a citizen?*
Are you a politically exposed person?*
Please provide further details*
Other
Policyholder Details
Salutation
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY

Gender*
Occupation*
Address 1
Address 2
Town/City*
Country*
Contact No.
Email*

Are you a resident or citizen?*
Of which country are you a citizen?
Are you a politically exposed person?*
Please provide further details
Total Policyholders

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INSURANCE DETAILS
Period of Insurance
From:*
Date Format: DD slash MM slash YYYY
Upto:*
Date Format: DD slash MM slash YYYY
Type of Insurance Coverage?*
Type of Insurance Coverage?*
Type of Insurance Coverage?*
Has any insurer ever declined your proposal, required an increase in premium or imposed special conditions or cancelled or not invited renewal in respect of yourself or any other person who will drive?*
- Yes
- No
Please provide additional details*
Please Sign Here
Do you or does any other person who will drive suffer from any physical impairment?*
- Yes
- No
Please provide additional details*
Have you or any other person who will drive ever been convicted by a court of any offence in connection with a motor vehicle?*
- Yes
- No
Please provide additional details*
Have you or any other person who will drive the vehicle received any penalties in relation to traffic or motor vehicle offences in the last 5 years?*
- Yes
- No

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DRIVER DETAILS
Will there be any other persons using this vehicle who*
a. is 25 years or under
b. is holder of a valid license for 2 years or less,
c. has had any vehicular accident(s), had any vehicular claims or experienced any vehicular losses in the last 2 years
- Yes
- No
Persons
Driver
First Name*
Last Name*
Driver's Date of Birth*
Date Format: MM slash DD slash YYYY

Driver's License Date of Inception*
Date Format: MM slash DD slash YYYY
Will there be a named driver on this policy*
- Yes
- No
Drivers
Driver
First Name*
Last Name*
Driver's Date of Birth*
Date Format: MM slash DD slash YYYY

Driver's License Date of Inception*
Date Format: MM slash DD slash YYYY
Are you now or have you been insured in respect of any Motor Vehicle?*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select your current insurer*
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Please select those insurers where you have been insured for the past five years*
Hold CTRL on Windows or CMD on MAC and click to select more than one insurer
Have you or any other person who will operating the vehicle been involved in any vehicular accidents, had any vehicular claims or experienced any vehicular losses in the last 5 years?
- Yes
- No
How many accidents/claims/losses in total in the last 5 years?*
First accident/claim/loss
In what year did this accident/claim/loss occur?*
Who was adjudged/assigned liable?*
Please provide additional details*
Please state estimate of damage sustained by you*
Please enter a number greater than or equal to 0.
Please state estimate of damage sustained by Third Parties*
Please enter a number greater than or equal to 0.
Second accident/claim/loss
In what year did this accident/claim/loss occur?*
Who was adjudged liable?*
Please provide additional details*
Please state estimate of damage sustained by you*
Please enter a number greater than or equal to 0.
Please state estimate of damage sustained by Third Parties*
Please enter a number greater than or equal to 0.
Third accident/claim/loss
In what year did this accident/claim/loss occur?*
Who was adjudged liable?*
Please provide additional details*
Please state estimate of damage sustained by Third Parties*
Please enter a number greater than or equal to 0.
Please state estimate of damage sustained by you*
Please enter a number greater than or equal to 0.
Fourth accident/claim/loss
In what year did this accident/claim/loss occur?*
Who was adjudged liable?*
Please provide additional details*
Please state estimate of damage sustained by Third Parties*
Please enter a number greater than or equal to 0.
Please state estimate of damage sustained by you*
Please enter a number greater than or equal to 0.
Fifth accident/claim/loss
In what year did this accident/claim/loss occur?*
Who was adjudged liable?*
Please provide additional details*
Please state estimate of damage sustained by Third Parties*
Please enter a number greater than or equal to 0.
Please state estimate of damage sustained by you*
Please enter a number greater than or equal to 0.
Please Sign Here
Please select the amount of years accident free?
Are you entitled to any No Claim Discount?
- Yes
- No
Please select the amount:*
Please Sign Here

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VEHICLE DETAILS
Vehicle Registration Number*
Make*
Model*
Body Type
Roof Type
Yr. of Manufacture*
HP / CC*
HP / CC Value*
Please enter a number greater than or equal to 0.
Engine No.
Chassis No.*
Vehicle Seating*
Please enter a number greater than or equal to 0.
Value of Vehicle
Please enter a number greater than or equal to 0.
Value of Vehicle*
Please enter a number greater than or equal to 0.
Signature
What is the primary use of the vehicle?*
Other:*
Was any modification done to the vehicle?*
- Yes
- No
Please describe modifications*
Does any Financial Institution hold an interest in the vehicle?
Does any Financial Institution hold an interest in the vehicle?*
- Yes
- No
Please provide details of mortgagee*
Will the vehicle be stored in a locked garage?
Will the vehicle be stored in a locked garage*
- Yes
- No

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ADDITIONAL BENEFITS
Do you require Windscreen Coverage?*
- Yes
- No
Please state the amount of coverage*
Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*
Do you require cover for Motor Perils?*
- Yes
- No
(Motor Perils include damage arising from Hurricanes, Earthquakes and Floods)
Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*
Do you require cover for Riot and Strike?*
- Yes
- No
Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*
Do you require Loss of Use coverage?*
- Yes
- No
Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*
Do you require roadside assistance?*
- Yes
- No
Signature*
- Type-in Signature
- Digital Signature
Signature*
Please sign here*

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Signature*
- Type-in Signature
- Digital Signature
Signature*
Signature*
Signature (Second Policyholder)*
Signature (Second Policyholder)*
Signature (Third Policyholder)*
Signature (Third Policyholder)*
Signature (Fourth Policyholder)*
Signature (Fourth Policyholder)*
Declaration*
- By signing or printing my name, I agree that this signature will be an electronic representation of my signature for all purposes when I use them on this document, just the same as a wet ink signature on paper.
Date*
Date Format: DD slash MM slash YYYY
Branches
If this form is being completed at a Gulf Branch, please select the name of the Branch
Would you like this form to be e-mailed to an additional person?*
- Yes
- No
Email*

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Motor Proposal Form

Step 1 of 7 - PROPOSER`S DECLARATION

PROPOSER DETAILS

Policyholder Details

Policyholder Details

INSURANCE DETAILS

Period of Insurance

DRIVER DETAILS

Driver

Driver

First accident/claim/loss

Second accident/claim/loss

Third accident/claim/loss

Fourth accident/claim/loss

Fifth accident/claim/loss

VEHICLE DETAILS

ADDITIONAL BENEFITS