Exagio Insurance Group – Exagio House 1 866 206 8919
10 Washington St, Boston MA 02108 e enquiry@exagioi nsurance.com
PO Box 55123, Boston MA 02284-1234 w www.exagioinsurance.com
Tailoring insurance for your needs
Page 1 of 2
VEHICLE INSURANCE DISCLOSURE FORM
This is a record of the online answers you submitted as part of our Duty of Disclosure process. This information has
been used as the basis of the insurance policy provided to you. Please note that we may reduce or refuse to pay a
claim, or cancel a policy if reasonable care has not been taken to submit accurate information.
Disclosed on: Thursday, August 24, 2023 at 10:31 PM
Disclosed by: Lynn Dickinson
For Policy No: EXG320380355
VEHICLE DETAILS
Year: Make:
Provide the year, make and model of
2017 Chevrolet
your vehicle
Model: Body Type:
Malibu Premier FWD Sedan
Series Model:
Premier w/2 Litre Engine with 250 hp, Dual Electric Motors, 4 dr Sedan
with 15.8 Gal. Tank, Front Wheel Drive, 5 Passenger Seating, Five Star
Crash Test Rating
What is the VIN of your vehicle? 4Y1SL65848Z411439
Is this vehicle currently registered?
Yes No
Is this a brand new vehicle? Yes No
DRIVER INFORMATION
What is the name of the main driver? Ms Lynn Dickinson
Main driver’s date of birth? January 11, 1960
Address where vehicle is usually kept? Apt #1234
1499 Lynn Street
Cambridge MA 02138
EXG0010010 / 00123456
Exagio Insurance Group. United States NAIC: 12345
Exagio Insurance Group – Exagio House 1 866 206 8919
10 Washington St, Boston MA 02108 e enquiry@exagioi nsurance.com
PO Box 55123, Boston MA 02284-1234 w www.exagioinsurance.com
Tailoring insurance for your needs
Page 2 of 2
OTHER DRIVERS
How often do other people drive the Never
vehicle?
Regularly (weekly)
Occasionally (no more than once a fortnight)
Can you please name the other drivers? Other Drivers Names Date of Birth
Mr David Dickinson June 01, 1960
Ms Marie Dickinson July 25, 1982
VEHICLE HISTORY
When did you purchase the vehicle? March 27, 2019
What price was paid for the vehicle? $46,800
SECURITY DEVICES
Has the vehicle been fitted with any of Car Alarm System Yes
these security devices?
Immobiliser Yes
Electronic Tracking System No
Transmission Lock Yes
INSURANCE EXTRAS
Please tick the extras that are required.
Roadside Assistance
Keys Replacement Cover
Excess-free windscreen protection
Hire car if theft or fire
Choice of own repairer
EXG0010010 / 00123456
Exagio Insurance Group. United States NAIC: 12345
