Motor Vehicle Insurance Application accepted! Application No.：EB123456
Name of Proposer:
Mr.
Tom, Ren
(Surname, Given Name)
HKID No.:
C387979(A)
Sex:
M
Age:
30
Occupation:
IT
Correspondence Address:
18A, The World Finance Center
Luohu District, Shenzhen
Email Address:
tomren@cmbwinglungbank.com
Telephone No.:
88888888 (Home)
66666666 (Office)
18988888888 (Mobile)
Period of Insurance:
(both dates inclusive)
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):
2,600.00
(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.
This application is subjected to final approval of CMB Wing Lung Insurance Co. Ltd. Our staff will contact you on the next working day.
Thank you for using Motor Vehicle Insurance Application Service.
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