Proposal Form Please complete and submit at least one week prior to your Morgan Hire Experience. Hire Insurance Form New 03/26 Personal Details Title * Full Name * Age * Email * Permanent Home Address including Postcode * Temporary Address including Postcode (if applicable) Phone Details (necessary in event of claim) Mobile * Home Business Where did you hear about our Morgan Hire? Devon Life Ley Arms Gidleigh Park Used before Recommended by family or friend OtherOther Health Declarations Expiry date of your UK Driving Licence * Have you had your licence renewed by DVLA (following your 70th birthday)? * Yes No If yes, please provide full details * Have you had any restrictions placed on your licence by DVLA? * Yes No If yes, please provide full details * Have you suffered from any medical condition that requires disclosure to DVLA?* * Yes No * Advice regarding which medical conditions require disclosure to DVLA can be found at www.directgov.uk/en/motoring, by calling 0300 7906807 or by consulting your GP. If yes, please provide full details * Has this medical condition been reported to DVLA, and if so have any further restrictions been placed on your licence? * Yes No If yes, please provide full details * Section Have you been advised by your GP not to drive a vehicle for any period within the last 3 years? * Yes No If yes, please provide full details * Have you had an eyesight test within the last 2 years? * Yes No If yes, please provide full details * Employment Details Business or Occupation * If you have a part-time or secondary business or occupation please give details. Business/Works Address inc Postcode * Driving the Vehicle Have you previously driven the make and model of the vehicle being hired and/or you familiar with the proper operation of the vehicle’s controls? * Yes No Will the vehicle be used ONLY for social, domestic and pleasure purposes? * Yes No If you have answered NO please give full details of intended use below: Please show full period full driving licence held * Will the vehicle be used outside the United Kingdom? * Yes No Additional Driver Will there be an additional driver(s)? * Yes No Additional drivers are chargeable – please enquire for details. Additional Driver’s Full Name * Additional Driver’s Age * Additional Driver’s Occupation * Copy of Additional Driver’s Licence * Drop a file here or click to upload Choose File Maximum file size: 3MB File types allowed: jpeg, gif, png, pdf Expiry date of their UK Driving Licence * Additional Driver’s Health Declarations Have they had their licence renewed by DVLA (following their 70th birthday)? * Yes No If yes, please provide full details * Have they had any restrictions placed on their licence by DVLA? * Yes No If yes, please provide full details * Have they suffered from any medical condition that requires disclosure to DVLA?* * Yes No * Advice regarding which medical conditions require disclosure to DVLA can be found at www.directgov.uk/en/motoring, by calling 0300 7906807 or by consulting your GP. If yes, please provide full details * Has their medical condition been reported to DVLA, and if so have any further restrictions been placed on their licence? * Yes No If yes, please provide full details * Have they been advised by their GP not to drive a vehicle for any period within the last 3 years? * Yes No If yes, please provide full details * Have they had an eyesight test within the last 2 years? * Yes No If yes, please provide full details * Period of hire – from Date from * Time * 121234567891011 : 0030 AMPM Period of hire – to Date to * Time * 121234567891011 : 0030 AMPM Motoring History Do you or any of the drivers to be covered have any physical or mental defect or infirmity requiring licence referral to Driver and Vehicle Licensing Agency? * Yes No Please give relevant details including any licence restrictions below * Have you or any of the drivers to be covered had less than twenty four months experience under a full United Kingdom driving licence applicable to the type of vehicle being hired? * Yes No Have you or any of the drivers to be covered resided permanently outside the United Kingdom during the last three years? * Yes No Please give details of the country of residence for being in the UK, e.g holiday, attending rally/tour below * Have you or any of the drivers to be covered had any motor insurance proposal declined or has any insurer not invited renewal or refused to renew or cancelled a policy or imposed special conditions (e.g premium loading, cover restrictions or stipulated that the first part of any loss should be borne)? * Yes No Additional Information If you require extra space for any answers to any of the questions, please us the field below Have you or any of the drivers to be covered been involved in a motoring accident or loss in the last 3 years? * Yes No Please give details including dates, circumstances, and costs below * Have you or any of the drivers to be covered been convicted or received notice of intended prosecution of any motoring offences in the last 5 years? * Yes No Please give details including dates, circumstances, and costs below * Have you or any of the drivers to be covered been disqualified from driving in the last 10 years? * Yes No Please give details including date of conviction, conviction code, details of any points, fines, and length of ban below * Documentation A copy of your driving licence, passport and/or a utility bill must be supplied, otherwise delays can be expected on collection of your Morgan. Driving Licence * Drop a file here or click to upload Choose File Maximum file size: 3MB File types allowed: jpeg, gif, png, pdf Passport OR Utility Bill * Drop a file here or click to upload Choose File Maximum file size: 3MB File types allowed: jpeg, gif, png, pdf You are reminded of the need to disclose any fact, which the insurers would take into account in the assessment and acceptance of the proposal. If you have any doubt as to whether certain facts are relevant, please consult Berrybrook Motors 01392 833301 It is an offence under the Road Traffic Acts to make any false statement or withhold any material information for the purpose of obtaining motor insurance. 1984 Data Protection Act Insurers maintain a motor insurance anti-fraud and theft register. In line with the 1984 Data Protection Act’s first data protection principle, which is concerned with ‘the obtaining of information’, we wish to advise you that insurers exchange information with each other to detect fraudulent claims. Declaration I declare that all statements and particulars given by me in this proposal, which I have read over, are correct and that no material fact has been omitted misrepresented or misstated. I am not aware of any other circumstances that are likely to affect the risk. I undertake that I shall not allow the vehicle to be driven by any person not authorised by Aon Ltd to drive the vehicle during the period of hire. * I Agree Submit If you are human, leave this field blank.
