(Please select "Vehicle Type" and "Insurance Cover")
Vehicle Type
Private Car
Commercial Vehicle
Insurance Cover
Comprehensive
Third Party Only
Registration Mark:
Estimated Market Value (HKD):
(For comprehensive cover only)
Make/Model/Body Type:
Engine Number:
Chassis Number:
Year of Manufacture:
Cylinder Capacity (c.c.):
Seating Capacity:
(Including driver)
Gross Vehicle Weight (Tonnes):
(For commercial vehicle)
Detail of Accessories:
Any Alterations:
Hire Purchase Owner:
Named Drivers of this vehicle (including proposer)
Name
Year of Birth
Year hold licence
Previous Insurance Record
No Claim Discount (%):
Previous Insurer:
Previous Policy No.:
Registration Mark:
Please answer the following questions
1.
Has any of your application for motor vehicle insurance been declined ?
Yes
No
2.
Have you / the named drivers been penalized for any traffic accident during the past three years ?
Yes
No
3.
Is your / the named drivers' hearing or sight in anyway impaired, or do you have any physical defect or infirmity ?
Yes
No
4.
Have you ever made a claim against any insurer in respect of any traffic accident ?
Yes
No
Please give details if the answer to any of the above is "Yes" :-
Declaration
I/We hereby apply for insurance as set out in the Company's Motor Insurance Policy, and I/we hereby warrant that the above particulars are true and agree that this proposal shall be the basis of the contract between myself/ourselves and the Company.
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