From 2010/01/20 (yyyy/mm/dd) To 2011/01/20
(yyyy/mm/dd)
Collection of Policy:
to be mailed to correspondence address
Particulars of Vehicle
(Please select "Vehicle Type" and "Insurance Cover")
Vehicle Type
Private Car
Insurance Cover
Comprehensive
Registration Mark:
01000086
Estimated Market Value (HKD):
1,000,086.00
(for comprehensive cover only)
Make/Model/Body Type:
Make
Engine Number:
888888
Chassis Number:
666666
Year of Manufacture:
10
Cylinder Capacity (c.c.):
1600
Seating Capacity:
5 (Including driver)
Gross Vehicle Weight (Tonnes):
2600.00
(for commercial vehicle)
Detail of Accessories:
Accessories
Any Alterations:
no change
Hire Purchase Owner:
Hua Li
Named Drivers of this vehicle (including proposer)
Name
Year of Birth
Year hold licence
Tom Ren
1977
6
Previous Insurance Record
No Claim Discount (%):
0
Previous Insurer:
Bus
Previous Policy No.:
666666
Registration Mark:
no
Please answer the following questions
1.
Has any of your application for motor vehicle insurance been declined ?
Yes
2.
Have you / the named drivers been penalized for any traffic accident during the past three years ?
Yes
3.
Is your / the named drivers' hearing or sight in anyway impaired, or do you have any physical defect or infirmity ?
Yes
4.
Have you ever made a claim against any insurer in respect of any traffic accident ?
Yes
Please give details if the answer to any of the above is "Yes" :-
detail info for above questions.
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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