MOTOR INSURANCE PROPOSAL FORM

Personal Information

Physical Address and Mailing addressOccupation SELECT:: Admin Clerk Accounting Architect Auditor Automotive Banking Biotech Business Development Construction Consultant Customer Service Distribution Shipping Doctor Dentist Education Engineering Executive Facilities Finance Franchise General Business General Labour Government Grocery Health Care Hospitality - Hotel Human Resources Insurance Legal Admin Manufacturing Media - Journalism Nonprofit - Social Pharmaceutical Purchasing - Procurement Real Estate Research Restaurant - Food Supply Chain Telecommunications Training Transportation Other

Policy Number
First Name		Last Name
Landline		Mobile
Email
D.O.B	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	January February March April May June July August September October November December Month	Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988
Gender	SELECT:: Male Female
Civil Status	SELECT:: Single Married

Driving History

Driving Licence #		Class	A A1 B C1 C BE C1E CE SELECT::
Issue Year:	SELECT:: 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009	Issue Month	January February March April May June July August September October November December SELECT::

Please specify Claims made by you over the last Five years:

When would you like your insurance coverage to begin?

Month	January February March April May June July August September October November December SELECT::	Date	SELECT:: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year:	SELECT:: 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009	Vehicle Use	SELECT:: PERSONAL PERSONAL PLUS WORK HIRE OR REWARD

Insurance History (Last five years):

Name of Insurer Reasons for cancellation (If any):

(B) VEHICLE DETAILS:

	Vehicle 1	Vehicle 2	Vehicle 3
Registration No.
Make/Model
Chassis #
Engine #
Cubic Capacity or HP rating
Color
Anti-Theft Device	Alarm System Tracking System Elec. Immobiliser Fuel Disable Starter Disable Other SELECT	Alarm System Tracking System Elec. Immobiliser Fuel Disable Starter Disable Other SELECT	Alarm System Tracking System Elec. Immobiliser Fuel Disable Starter Disable Other SELECT
Value of Vehicle
Year of Manufacture
Type of Cover	SELECT ACT COMP FTPFT TP	SELECT ACT COMP FTPFT TP	SELECT ACT COMP FTPFT TP
Increased Third Party Limit
Year of first Registration in Zambia

DECLARATION I/We hereby declare that all the above statements and particulars which I/we have read and checked are true Correct and Complete and contains information to me/us affecting the proposed insurance and trust this and any other statement made by me/us to PROFESSIONAL INSURANCE CORPORATION LIMITED shall be THE BASIS OF AND INCORPORATION IN THE CONTRACT BETWEEN ME/US AND THE COMPANY. I HAVE UNDERSTOOD THAT IN CASE OF PARTIAL LOSS, IF SUM INSURED FALLS SHORT OF MARKET VALUE ON THE DATE LOSS, I HAVE TO BEAR THE PROPORTION OF SUCH SHORT FALL TO THE MARKET VALUE. I/WE FURTHER AGREE TO ACCEPT INSURANCE ON THE TERMS AND CONDITIONS SET FORTH IN THE COMPANY′S POLICY. I/WE FURTHER AGREE TO ACCEPT INSURANCE ON THE TERMS AND CONDITIONS SET FORTH IN THE COMPANY′S POLICY (If signing for a company indicates authority and state the name of the Company/Agency). IMPORTANT NOTICE This Proposal will form the basis of a legally contract and absolute truth and accuracy in answering the questions is essential. Before signing the SPECIAL DECLARATION ensure that ALL questions are answered correctly. Failure to comply may result in the cancellation of cover and/or the reputation of any claim If answers are completed by any agent the Proposer must sign and the answers will be deemed to be the proposer′s answers. Any other person signing will be deemed to have signed as the agent of the proposer with the full knowledge and consent of the proposer. The policy includes Hiring, carriage of passengers for hire or carriage of fare paying passengers racing speed or other contests rallies trials carriage of explosive of carriage of any load or passengers exceeding with the capacity for which it is constructed or licensed to carry or use for any purpose in connection with the motor trade. The indemnity to the insured in connection with any vehicle shall operate write such vehicle is in the custody or control of a member of the motor trade for the purpose of its overhaul upkeep of repair. Date: Signature :
By clicking on SUBMIT you are confirming to having read the SPECIAL DECLARATION and NOTES.