Excess Buy Back Motor Proposal Form 1Tell us about yourself2Details of vehicle usage3Previous insurance details4Driver history5Vehicle details6Vehicles to cover7Declare this proposal Personal DetailsFull Name(Required) First Name Surname Initials Identity Number(Required) Broker or Agent Email Address(Required) Postal Address(Required) Physical Address(Required) Telephone Cellphone(Required) (Premiums are to be paid upfront before cover commences) Vehicle UsageWill the Vehicle/s be used for social domestic and pleasure purposes only?(Required) Yes No Will the Vehicle/s be used for hire or reward?(Required) Yes No Will the Vehicle/s be used for business or professional purposes?(Required) Yes No If the vehicle will be used for any other purpose give full details Previous Insurance DetailsDo you have any previous motor insurance?(Required) Yes No Name of Current Motor Insurer(s) & type of cover(Required) Policy Number(Required) Attach Proof(Required) Drop files here or Select files Max. file size: 64 MB. Driver HistoryIn the past 5 years has any person who will drive the vehicle/si) been convicted of any driving offence or have any prosecution pending?(Required) Yes No Please give details for (i)(Required) ii) suffered from diabetes, fits or any complaint of the heart or other physical or mental infirmity?(Required) Yes No Please give details for (ii)(Required) Vehicle ModificationsHas the vehicle/s been specially adapted or structurally modified to increase performance.(Required) Yes No Please give details(Required) Is the vehicle registered in your name?(Required) Yes No State the name in which the vehicle/s are registered(Required) First Name Surname Are you the owner of the vehicle/s?(Required) Yes No State the name of the owner(Required) First Name Surname Vehicle CoverPlease give full details of all Motor Cars, Motor Cycles, Trailers and Caravans to be insured.(Required)Click (+) to add a new row for more vehicles. ModelYearReg. NoMarket ValueBasicAgeTotalVoluntary Excess Add RemoveThe under-mentioned information MUST be provided for the past 5 years 2021(Required)Total Number of Vehicles Owned by ProposerTotal Number of Accidents and LossesTotal CostBrief Circumstances of Loss2020(Required)Total Number of Vehicles Owned by ProposerTotal Number of Accidents and LossesTotal CostBrief Circumstances of Loss2019(Required)Total Number of Vehicles Owned by ProposerTotal Number of Accidents and LossesTotal CostBrief Circumstances of Loss2018(Required)Total Number of Vehicles Owned by ProposerTotal Number of Accidents and LossesTotal CostBrief Circumstances of Loss2017(Required)Total Number of Vehicles Owned by ProposerTotal Number of Accidents and LossesTotal CostBrief Circumstances of Loss Declaration(Required) I hereby declare the statement belowI declare that the answers in this proposal are full and true and that I have withheld no information whatever that may tend in any way to increase the Company’s risk or influence their decision regarding this proposal and I undertake to exercise all ordinary and reasonable precautions for the safety of the property proposed for insurance. I agree that this proposal and declaration shall be the basis of the contract between me and Lidwala Insurance Company and I agree to accept a Policy subject to the usual conditions endorsed thereon. The insurance does not commence until acceptance has been confirmed by the Insurer.Date(Required) DD slash MM slash YYYY
