Statement of Fact

What you have told us

Created Date: 23/10/2011 Document ID: 2011/4839133/3447129/GOC

This is an important document - please keep it in a safe place. There is no need to return this form unless any of the details are incomplete or incorrect. You are required to provide us with all material facts when applying for this insurance. Material facts are those facts which an insurer would regard as likely to influence the acceptance and/or assessment of your proposal for insurance. Your acceptance of this Statement will be regarded as confirmation that you have provided us with all material facts and that the information provided on this Statement is true to the best of your knowledge and belief. If you are in any doubt as to whether any facts are material to this proposal for insurance you should disclose them. This Statement of Fact is the basis of the contract between you and us. Failure to disclose all relevant information or the provision of false or inaccurate information could invalidate your insurance or result in a claim not being paid. It is an offence under the Road Traffic Act to make any false statement or withhold any material information for the purpose of obtaining a Certificate of Motor Insurance. If any of the details shown appear to be incomplete or incorrect please ring your Insurance Intermediary Collingwood Insurance Services (UK) Ltd immediately on 0845 470 0014. Please let them know of any amendments WITHIN 7 DAYS of receipt of this Statement. They will advise you of any revised premium and/or changes to terms or conditions that may result from amendments you make and send you a revised Statement. You should keep a record (including copies of letters) of all information supplied by you for the purpose of entering into this contract of insurance. A specimen policy wording is available via your intermediary's website www.collingwoodannuallearners.co.uk Should you make a claim you may be required to provide a copy of your driving licence. If you cannot provide this, settlement of your claim may be prejudiced. The parties are free to choose the law applicable to this insurance contract. Unless specifically agreed to the contrary this insurance shall be subject to English Law. Collingwood Insurance Company Limited reserves the right to decline any proposal for insurance.

Section 1: Proposer Details Name: CHELSEA PHILLIPS Permanent Address: 34 SHALDON CRESCENT, PLYMOUTH, You have confirmed the following information concerning your driving history: 1.

Commencing: Date of Birth: 18/11/1992

24/10/2011 17:30 Licence Type: UK/EU Provisional

Postcode:

PL53QY

You have not received any motoring convictions in respect of the following licencing authority offence codes in the last 5 years nor are there any such convictions currently pending: All conviction codes prefixed with 'AC' Conviction codes CD40, CD50, CD60, CD70, CD80, CD90 All conviction codes prefixed with 'DD' All conviction codes prefixed with 'DR' Conviction codes MS40, MS50, MS60, MS70, MS80 All conviction codes prefixed with 'UT'

2. 3.

You have no more than 6 penalty points shown on your driving licence. You have never been disqualified or banned from driving nor had your licence revoked.

Section 2: Vehicle Details Make, Model, Type Registered vehicle Keeper: FORD FIESTA LX 16V Policy Holder Registration Number: P547CDV

You have confirmed that the vehicle does not have any performance enhancing modifications. You have confirmed that the vehicle is not currently impounded by the Police Authorities. Section 3: Cover and Policy Information Cover Required: THIRD PARTY ONLY Driving Restrictions: INSURED ONLY TO DRIVE

Permitted Use: Social, Domestic & Pleasure & for Commuting to and from the Policyholder's fixed place of work. At all times the Policyholder must be undergoing driving tuition. The policyholder must at all times be accompanied by a person aged over 21 who has held a full UK/EU licence for a minimum of 3 years.

Collingwood Insurance Company Limited is licensed by the Financial Services Commission in Gibraltar under the Financial Services (Insurance Companies) Act to carry on insurance business in Gibraltar. Collingwood Insurance Company Limited. Registered in Gibraltar (Reg. No. 89988). Registered office: Montagu Pavilion, 8-10 Queensway, Gibraltar.

Page 1 of 4

Important information about your insurance

What to do in the event of an accident or an incident likely to give rise to a claim Call the 24 hour Claims Helpline - Telephone 0845 3700 008
After any accident or incident telephone our 24 hour claims helpline as quickly as possible. This is regardless of whether you believe that you were at fault or not or whether you wish to make a claim under the policy. The sooner you contact us the quicker we can help in sorting out your/the other driver's claim. Delay in notifying us of an accident or incident may invalidate your right to claim. Quote your policy number and give all the information about the incident. If your claim is due to theft, attempted theft or vandalism you must also inform the Police and obtain a crime reference number. We will deal with your claim and claims made against you, as quickly and fairly as possible. Please read the General Conditions in your policy booklet. For our joint protection telephone calls may be recorded and monitored by us and our service providers.

Using our Approved Repairer Service

To reflect the savings that we achieve when repairs are undertaken by our approved repairers, the level of your excess will be reduced by 100 if you use a member of our approved repairer network to repair your vehicle. Please call 0845 3700 008 to find the nearest approved repairer to you. This reduced excess only applies if the vehicle is repairable. The other benefits you receive by using our approved repairer will depend on the level of policy cover you selected but can include: FREE courtesy car while your car is being repaired FREE collection and re-delivery FREE car cleaning service Repairers' work guaranteed for three years

Legal Expenses Insurance

Automatic legal expenses insurance applies to all vehicles insured with us. Separate cover is provided by Brit Insurance Limited, arranged by ARAG Plc on their behalf. Further information concerning this separate insurance arranged through ARAG Plc can be obtained from your insurance intermediary or via www.collingwood.gi By telephoning the 24 hour claims helpline number above our service providers will be able to put you in touch with your legal expenses insurer as well as dealing with the claim under your motor insurance policy.

Keeping us informed
Police Proceedings - Please contact us immediately if the driver of your vehicle receives a summons from the police. Civil Proceedings - If you receive any summons, writ or claim against you, this should be passed to us immediately without any action being taken on your part. Before you commence proceedings against or accept a compromise settlement from any person involved in an accident please contact us to make sure we have no objections

Collingwood Insurance Company Limited is licensed by the Financial Services Commission in Gibraltar under the Financial Services (Insurance Companies) Act to carry on insurance business in Gibraltar. Collingwood Insurance Company Limited. Registered in Gibraltar (Reg. No. 89988). Registered office: Montagu Pavilion, 8-10 Queensway, Gibraltar.

Page 2 of 4

Keeping us updated - changing your insurance

You are reminded that your premium is based on the information you supplied at the start of the insurance or at a subsequent change or renewal. You must tell your insurance intermediary of any changes immediately they occur. Some examples are: You pass your driving test. A change of car, or you purchase another car to which you want cover to apply. You wish a new driver to be covered. Someone who drives the car receives a motoring or other conviction, has a pending prosecution, suffers from a medical condition or has a claim on another policy. The car is changed or modified from the manufacturer's standard specification or you intend to change or modify it (including the addition of optional-fit accessories such as spoilers, skirts, alloy wheels, etc). A change of occupation (full or part-time) by you or any other driver. A change of address or where the car is normally kept. A change in the use of the car. The car is involved in an accident no matter how trivial. A change of the main user of the car.

This is not a full list and if you are in any doubt you should advise your Insurance Intermediary for your own protection. If you do not tell us about changes, your insurance may not cover you fully or at all.

Data Protection
We are governed by the Data Protection legislation applicable in both the United Kingdom and Gibraltar. Under this legislation we are required to tell you the following information. It explains how we may use your details and tells you about the systems we have in place that allow us to detect and prevent fraudulent applications and claims. The savings that we make help us to keep premiums and products competitive. On payment of a small fee you are entitled to receive a copy of the information we hold about you. If you have any questions, or you would like to find out more about this notice you can write to the Compliance Officer at Collingwood Insurance Company Limited. Information on products and services We may use the details you have provided to send you information about our other products and services or to carry out research. We may contact you by letter, telephone or e-mail. Please be reassured that we won't make personal details available to any companies other than those that are contracted by us to provide services relating to your insurance with us. If you would prefer not to receive information from us or those companies who provide services on our behalf, simply tell your intermediary when you call or write to them. Motor Insurance Database (MID) Information relating to your insurance policy will be added to the Motor Insurance Database ("MID") managed by the Motor Insurers' Bureau ("MIB"). MID and the data stored on it may be used by certain statutory and/or authorised bodies including the Police, the DVLA, the DVANI, the Insurance Fraud Bureau and other bodies permitted by law for purposes not limited to but including: (a) (b) (c) (d) Electronic Licensing; Continuous Insurance Enforcement; Law enforcement (prevention, detection, apprehension and or prosecution of offenders); The provision of government services and or other services aimed at reducing the level and incidence of uninsured driving.

If you are involved in a road traffic accident (either in the UK, the EEA or certain other territories), insurers and or the MIB may search the MID to obtain relevant information. Persons (including his or her appointed representatives) pursuing a claim in respect of a road traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID. It is vital that the MID holds your correct registration number. If it is incorrectly shown on the MID you are at risk of having your vehicle seized by the Police. You can check that your correct registration number details are shown on the MID at www.askmid.com

Fraud Prevention, Detection and Claims History

In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police; Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this. We and other organisations may also search these agencies and databases to: Help make decisions about the provision and administration of insurance, credit and related services for you; o Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your accounts or insurance policies; o Check your identity to prevent money laundering, unless you furnish us with other satisfactory proof of identity; o Undertake credit searches and additional fraud searches.

We can supply on request further details of the databases we access or contribute to.

Collingwood Insurance Company Limited is licensed by the Financial Services Commission in Gibraltar under the Financial Services (Insurance Companies) Act to carry on insurance business in Gibraltar. Collingwood Insurance Company Limited. Registered in Gibraltar (Reg. No. 89988). Registered office: Montagu Pavilion, 8-10 Queensway, Gibraltar.

Page 3 of 4

Claims History
Under the conditions of your policy you must tell us about any Insurance related incidents (such as fire, water damage, theft or an accident) whether or not they give rise to a claim. When you tell us about an incident we will pass information relating to it to industry databases. We may search these databases when you apply for insurance, in the event of any incident or claim, or at time of renewal to validate your claims history or that of any other person or property likely to be involved in the policy or claim.

Other Insurers
We may pass information about you and this policy to other insurance companies with which we either reinsure our business or who are dealing with a claim made under this policy. In addition, information may be passed to other insurance related organisations in common with industry practice. These companies may be located in countries outside the UK but within the European Economic Area (EEA).

What to do if you have a complaint

We are dedicated to providing you with the high standard of service you have the right to expect. If we fall below this standard or you are unhappy with any aspect of our service please follow the steps below: Step 1 - What you should do first: If you have any questions or concerns about the way your policy was sold to you please contact your Insurance intermediary to report your complaint. If you have a complaint about a claim, please contact the person handling your claim in the first instance. You will find their name and phone number on any letters they have sent to you. If you have a complaint about the cover in this policy document, or our service, please contact our service providers in the United Kingdom, quoting your policy number which is shown on the Schedule: Compliance Manager, Collingwood Insurance Services (UK) Ltd, Collingwood House, Redburn Court, Earl Grey Way, North Shields, Tyne and Wear, NE29 6AR Step 2 - If you are not satisfied with the response you receive you can refer your complaint to: The Chief Executive Officer, Collingwood Insurance Company Limited, 3/1 Waterport Place, Gibraltar Step 3 - In the event that you remain dissatisfied you can contact the Financial Ombudsman Service (FOS): Telephone: 0845 080 1800 or E-mail: complaint.info@financial-ombudsman.co.uk Whilst we are bound by the decision of the FOS, you are not. Following the complaints procedure does not affect your right to take legal action.

Financial Services Compensation Scheme (FSCS)

All Collingwood Insurance Company Limited policies issued in the UK for individual customers or small businesses' are covered by the Financial Services Compensation Scheme. You may be entitled to compensation from the scheme if your insurer cannot meet its obligations (e.g. if it goes out of business or into liquidation or is unable to trade). Further information about compensation scheme arrangements is available from the FSCS at www.fscs.org.uk or by telephone: 0207 892 7300.

Collingwood Insurance Company Limited is licensed by the Financial Services Commission in Gibraltar under the Financial Services (Insurance Companies) Act to carry on insurance business in Gibraltar. Collingwood Insurance Company Limited. Registered in Gibraltar (Reg. No. 89988). Registered office: Montagu Pavilion, 8-10 Queensway, Gibraltar.

Page 4 of 4