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Application Form

This document is an application form for motor insurance. It requests information about the applicant such as their name, address, contact details, vehicles to be insured, and driver details. The applicant is asked to provide details on the vehicles, including make, value, identification numbers, and whether security devices are installed. Coverage options including liability limits and territorial coverage are outlined. The applicant must declare that the information provided is accurate and material facts have not been withheld.

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pelaq la wei
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© Attribution Non-Commercial (BY-NC)
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105 views3 pages

Application Form

This document is an application form for motor insurance. It requests information about the applicant such as their name, address, contact details, vehicles to be insured, and driver details. The applicant is asked to provide details on the vehicles, including make, value, identification numbers, and whether security devices are installed. Coverage options including liability limits and territorial coverage are outlined. The applicant must declare that the information provided is accurate and material facts have not been withheld.

Uploaded by

pelaq la wei
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

APPLICATION FORM

Motor Insurance

Thank you for your enquiry

In order for us to offer you the best and most appropriate insurance cover, please take a
few moments to complete the Application Form.
If you have any questions about this Proposal please telephone or write to Resolution
Consultants LTD at:

Telephone/Fax: (3741) 557937


Email: recon@arminco.com
URL: www.recon.am

SECTION A - DETAILS

1) Name of Applicant:      

2) Local Postal Address:      

3) Telephone:       Fax:      

4) Principal Business (Occupation) of      


Applicant:

5) Number of Vehicles to be Insured:      

6) Do you own the vehicle?


YES NO
If “NO”, please indicate below the way they relate to you.
     

7) Please indicate the coverage required:


a) PD, Fire & Theft
b) Personal accident insurance of driver and passengers
c) Third Part Liability (TPL)

8) Required Sum insured for driver and passengers:


$5000 (per seat/per person), OR
$10,000 (per seat/per person)

Prepared by Resolution Consultants ltd 1


9) Required Limit of Third Party Liability
$5000
$10,000
$50,000
$100,000
$1,000,000
If required, please indicate:
Maximum Third Party Liability for Property Damage: US$      per accident
Maximum Third Party Liability for Physical Damage: US$      per accident
Maximum amount payable for legal costs: US$      per accident

10) Required period of cover, starting date:      

11) Territorial Limits Armenia NKR CIS Iran

SECTION B – VEHICLES DETAILS

ITEM /
1. 2. 3. 4. 5. 6.
Vehicle
1) Make/
                                   
Model/Color
2) Market value
of the vehicle                                    
US$
3) Sum insured                                    
US$
4) Reg. #                                    
5) Body #                                    
6) Engine #                                    
7) Year of
                                   
manufacture
8) Is the vehicle
fitted with anti-                                    
theft/alarm
devices?
9) State the
place of
overnight                                    
parking (garage,
etc.)
10) Is increased
cover required
for radio/audio
                                   
equipment?
If “Yes” give
details
11) Has the
vehicle any
external
damages?                                    
If “Yes” full
details to be
provided

Prepared by Resolution Consultants ltd 2


SECTION C – DRIVER DETAILS

Have the nominated


driver been involved in
any accident involving
Number of
a motor vehicle within
Years
Full Name Driver License # Date of Birth the past 3 years. If
Driving
"YES" full history to be
Experience
provided on a
separate sheet

1.                              


2.                              
3.                              
4.                              
5.                              
6.                              
Please, attach the copies of the vehicles’ technical passports

DECLARATION

To the best of my knowledge and belief the information provided in connection with this
proposal, whether in my own hand or not, is true and I have not withheld any material
facts. I understand that non-disclosure or misrepresentation of a material fact will
entitle      INSURANCE COMPANY to avoid this Insurance.

(A material fact is one likely to influence acceptance or assessment of this proposal by


      INSURANCE COMPANY. If you are in any doubt as to whether a fact is material
or not you must disclose it in the space below).
     

I understand that the signing of this proposal does not bind me to an insurance contract
but agree that, should a contract of insurance be concluded, this proposal and the
statements made therein shall form the basis of the contract.

Name of Applicant:      


Date:      

You must inform us of any change in circumstances, which will materially affect this Insurance.

Prepared by Resolution Consultants ltd 3

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