Car Solutions Insurance
Proposal form
Car insurance
Please complete this form in block capitals giving full answers. Tick boxes where appropriate.
If answer space is insufficient, please continue on a separate sheet of paper.
Whenever we refer to spouse in this document, we mean your husband, wife or partner you live with as if you
are married (including same sex partners).
Agents Reference
Zurich Quote Reference
Policy Number (to be completed by Zurich)
1
Proposer
Mr
Mrs
Miss
Ms
Other (please give details)
Dr
First name(s)
Surname
Date of
birth
Age
Sex (please tick):
Male
Female
What is your marital status? (e.g. single/married/divorced/widowed)
Address
Town
CountyPostcode
Daytime telephone number (inc.STD code)
Occupation (including any part-time work and usual occupation if unemployed)
Nature of employers business (or your own if self-employed)
Are you a homeowner (please tick):
Yes
No
Are there any children under 17 years of age living at home with you?
Yes
No
If you are a current member of a motoring organisation, please indicate which by ticking one of the below:
AA
2
RAC
Green Flag Ltd
Britannia
Other
Renewal month
Car
Date of
purchase
Registration mark#
Make and model of car (e.g. Ford Escort LX)
cc
Year
Estimated
annual mileage
Estimated value*
Only cars registered in the UK are acceptable.
*This question is asked for underwriting purposes only – all claims will be settled on a market value basis.
#
am / noon / pm
1. Cover required from
on
Cover will not commence until a cover note or certificate of insurance has been issued.
2. State the Postcode where the car is normally kept overnight
3.Is the car kept in:
Private garage
Driveway
Road
Car Port
4. Is your car fitted with a security system?
2
Yes
a) Alarm/immobiliser Yes
No
If ‘Yes’ state make and model
b) Tracking device
No
If ‘Yes’ state make
Yes
Car Park
Other
No
Car (continued)
5. Has the car been altered/modified/changed in any way (including optional extras)
from the manufacturer’s standard UK design or specification?
Yes
No
a) Engine/performance
Yes
No
b) Body work/trim (e.g. spoilers, body kit, sound systems)
c) Wheels/suspension/brakes (e.g. alloy wheels, wide wheels, lowered suspension)
Yes
No
Yes
No
6. a) Is your car right hand drive?
Yes
No
b) Manufactured for the UK/EC market
Yes
No
7. a) Are you the sole owner of the car?
Yes
No
b) Is the car registered in your name?
Yes
No
8. Do you or your spouse own any other vehicle or have private use of a
company vehicle?
Yes
No
If you have ticked any of the shaded boxes, please give full details.
3
Drivers
9. State name of main driver
10.Give details of all persons who to your knowledge may drive including yourself and spouse.
(If you have chosen our Solutions Plus policy the maximum number of additional drivers is two.)
Business or occupation
UK or EC Male or (full and part-time and usual
licence (full Full name of driver
Age female occupation if unemployed) Employers business or prov.)
You – the
proposer
4
Type of
Period
licence
held
Do they
own their
own car
History
11.Within the past five years, have you or any other person who may drive:
a)been convicted of any motoring offence?
Yes
No
b) incurred a fixed penalty resulting in endorsement of the licence?
Yes
No
c) any prosecution or Police enquiry pending?
Yes
No
If you have ticked any of the shaded boxes please complete the following:
Name
Date of offence
/ /
/ /
/ /
Date of conviction Offence code Penalty points Sentence and/or fine
/ /
/ /
/ /
3
History (continued)
12.In respect of any person who may drive, has any insurer
a)increased the premium or imposed special conditions?
Yes
No
b)refused to issue a policy, cancelled cover, or refused to renew your policy cover? Yes
No
If you have ticked either of the shaded boxes please give full details.
13.Have you or any other person who may drive had any accidents,
losses or claims (regardless of blame or whether covered by insurance
or not) during the past five years?
Yes
No
If you have ticked the shaded box complete the following details.
Name
Date of accident/loss Circumstances
5
/ /
/ /
/ /
Cost
£
£
£
Use
14.In addition to social, domestic and pleasure (which permits travelling to and from work), will the car be used:
6
a) for business purposes by yourself and/or your spouse?
Yes
No
b) for business purposes by any person other than yourself and/or your spouse?
If yes, such persons must be named in Q.10.
Yes
No
c) for hiring or for the carriage of passengers for hire or reward?
Yes
No
d) for commercial travelling or the promotion of sales?
Yes
No
e) for driving tuition?
Yes
No
f) in connection with the motor trade?
Yes
No
Note: Cover for business purposes not available on Solutions Plus policy.
Cover and no claim discount
15.Cover required Comprehensive
Third party fire and theft
Third party only
16.You may increase the standard £100* accidental £150
£200
damage excess to £150, £200, £250 or £350 in
return for a premium discount.
(*Please note the standard £100 is increased for inexperienced drivers, drivers
aged under 25 and certain categories of vehicles – refer to quote for details)
£250
£350
17.Driving Restriction
Yourself only
Yourself and spouse
Yourself and one
named driver
Yourself and two
named drivers
Yourself and named drivers
(not available for Solutions Plus)
Any driver excluding drivers under 25 (not available for Solutions Plus)
18.a) Are you claiming a No Claim Discount?
Yes
If you have ticked the shaded box attach insurer’s original renewal notice
and state number of years entitlement
4
b) Do you require No Claim Discount protection?
No
years
Yes
No
7
Options (comprehensive cover only in addition to our ‘inclusive’ Car Breakdown Cover)
19.Indicate which additional cover Option(s) you wish by ticking the appropriate box(es)
Home-Call Service
£22.26 (included free
with Solutions Plus)
Yes
No
Nationwide Breakdown Recovery Service
£40.28
Yes
No
European Breakdown & Accident Assistance
£53.00
Yes
No
All three options
£79.50
Yes
No
All prices quoted are correct at time of printing and include Insurance Premium Tax (IPT) at the current rate.
8
Payment methods
20.Indicate by ticking one box how you wish to pay the premium – see full details on next page.
9
Annually
Monthly by Direct Debit
Important notes
• You must tell us immediately if at any time any of the information on which this insurance is based is
incorrect or changes, for example you or anyone covered by this policy being convicted of an offence or
change of car or occupation. Failure to do so may result in your insurance no longer being valid and claims
not being met. If in doubt about any change, please let us know. The changes, if accepted by us, will apply
from the date indicated on your updated schedule. In this case we will be entitled to vary the premium
and terms for the rest of the period of insurance. You should keep a record (including copies of letters) of
all information supplied to us in connection with this insurance.
• A copy of this completed proposal form will be supplied to you on request within a period of 3 months
after its completion. If you would like to request a policy document, please call us and we will arrange
for this to be sent to you. Please refer to your covering letter for contact details.
• Your cancellation rights – If you decide that you do not want to accept the policy (or any future
renewal of the policy by us), please surrender the Certificate of Insurance to us or your insurance
advisor using the contact details provided on the covering letter within 14 days of receiving it (or for
renewals, within 14 days of your policy renewal date). We will only charge you on a pro rata basis for
the time we have been on cover subject to a minimum premium of £20 (plus insurance premium tax).
The balance of the premium will be returned to you when you have surrendered your certificate but
there will be no refund where you are cancelling the policy following a claim where the vehicle is a
total loss and not being replaced.
• UK Administration and Overseas Claims – Zurich Insurance plc holds your details in accordance with
the Data Protection Act 1998. In order to administer your insurance policy and any claims made against
the policy, Zurich Insurance plc may share personal data provided to us with other companies within
the Zurich Insurance Company Group and with business partners, including outside the European
Economic Area (EEA). If we do transfer your personal data, including where we propose a change of
underwriter, we make sure that it is appropriately protected.
• Motor Insurance Database – Information relating to your insurance policy will be added to the
Motor Insurance Database (“MID”) managed by the Motor Insurers’ Bureau (“MIB”). MID and the data
stored on it may be used by certain statutory and/or authorised bodies including the Police, the DVLA,
the DVANI, the Insurance Fraud Bureau and other bodies permitted by law for purposes not limited to
but including:
I. Electronic Licensing
II. Continuous Insurance Enforcement;
III. Law enforcement (prevention, detection, apprehension and or prosecution of offenders)
IV. The provision of government services and or other services aimed at reducing the level and
incidence of uninsured driving.
If you are involved in a road traffic accident (either in the UK, the EEA or certain other territories),
insurers and or the MIB may search the MID to obtain relevant information.
Persons (including his or her appointed representatives) pursuing a claim in respect of a road traffic
accident (including citizens of other countries) may also obtain relevant information which is held on
the MID.
It is vital that the MID holds your correct registration number. If it is incorrectly shown on the MID you
are at risk of having your vehicle seized by the Police. You can check that your correct registration
number details are shown on the MID at www.askmid.com
• The information supplied to us by you may be held on computer and passed to other insurers for
underwriting and claims purposes.
5
Important notes (continued)
• Fraud Prevention, Detection & Claims History – In order to prevent and detect fraud, we may at
any time:
– Share information about you with other organisations including the Police
– Undertake credit searches
– Check and/or share your details with fraud prevention and detection agencies
If false or inaccurate information is provided and fraud is identified, details will be passed to fraud
prevention agencies. Law enforcement agencies may access and use this information. We and other
organisations may also access and use this information to prevent fraud and money laundering, for
example when:
– Checking details on applications for credit and credit related or other facilities
– Managing credit and credit related accounts or facilities
– Recovering debt and tracing beneficiaries
– Checking details on proposal and claims for all types of insurance
– Checking details of job applicants and employees
Please contact us on the number shown on your policy documentation if you want to receive details
of the relevant fraud prevention agencies. We and other organisations may access and use from other
countries the information recorded by fraud prevention agencies.
• Claims History – Under the conditions of your policy you must tell us about any Insurance related
incidents (such as fire, water damage, theft or an accident) whether or not they give rise to a claim.
When you tell us about an incident we will pass information relating to it to the relevant database.
We may search these databases when you apply for insurance, in the event of any incident or claim,
or at time of renewal to validate your claims history or that of any other person or property likely to
be involved in the policy or claim.
• You should show this notice to anyone insured to drive your car covered under the policy.
• Product & Services – Unless you have advised us otherwise, we may share personal data that you provide
within the Zurich Insurance Company Group and with other companies that we establish commercial links
with so we and they may contact you (by mail, e-mail, telephone or other appropriate means) in order to tell
you about carefully selected products, services or offers that we believe will be of interest to you. If you do
not wish us to do this please tick here
10
Declaration
• I declare that to the best of my knowledge and belief all the answers are true and no material fact has
been omitted (see important notes above).
• I agree that if any answer has been written by any other person he/she shall for that purpose be
regarded as my agent and not an agent of the Company.
• I understand that if I elect to pay premiums monthly, the liability of the Company will cease in the
event of non-payment of any monthly premium on its due date but that I will always be given 7 days
written notice before cancellation takes effect.
• I have read the Important Notes Section and I understand how the policy data may be used and have
informed other parties related to this insurance accordingly.
Proposers signature
Day
Date
A specimen copy of the policy is available on request
6
MonthYear
Zurich Car Insurance
Optional Covers
If you have selected our Solutions comprehensive
cover you will automatically be provided with:
To ensure your complete peace of mind, our
Solutions comprehensive cover also offers three
additional cover options at what we believe to
be competitive prices:
Roadside Assistance, including:
• 24 hour roadside assistance for breakdowns
occurring more than 1/4 mile from the
customer’s home
• recovery of the car (plus driver and up to
seven passengers) to the nearest garage
after breakdown
• recovery of the insured car after theft
or vandalism
• a 60 minute service pledge (with £10
compensation if assistance is not received
within 60 minutes)
• a ‘phone messaging service to advise a friend
or family member of the breakdown.
Quality Comprehensive Car Insurance,
including:
• cover for accidental damage, fire and theft of
and from the vehicle
• audio equipment cover up to £500 (unlimited if
fitted by the vehicle manufacturer)
• accident damage cover
• use of our Quality Assured repairer scheme with,
– complimentary courtesy car during
accident repairs
– three year guarantee on workmanship
and parts
• a new replacement car if your car is written-off
within one year of registration
• loss of, or damage to a pushchair or wheelchair
up to £200
• personal effects cover up to £250
• £10,000 personal accident cover for you or a
member of your family who is involved in an
accident while travelling by car
• luggage trailer cover up to £250
• windscreen, window and sunroof glass
repairs, without any contribution or loss of
No Claim Discount
• cover for visits to Western Europe for up to 60
days per trip without the need for a Green Card
• the option to pay monthly by Direct Debit
• Uninsured Loss Recovery Service (with costs of
up to £100,000) and Motoring Legal Advice.
Full details of the extensive cover given are available
from your insurance advisor.
Please note that our Solutions comprehensive
cover carries a standard £100 excess in respect
of accidental damage, fire and theft.
A £60 excess applies in respect of windscreen
replacement if you use our approved repairer.
If you do not use our approved repairer the
excess will be increased to £100 and the
maximum we will pay for any claim after this
£100 deduction is £150.
You will not have to pay anything if the glass is
repaired and not replaced.
Option 1
Home-Call Service
£22.26
Our Home-Call Service gives you the added security
of our Breakdown Assistance cover either at home
or within a 1/4 mile radius of your home.
Option 2
Nationwide Breakdown Recovery Service £40.28
Our inclusive Breakdown Assistance provides
recovery of your car and passengers to the garage
nearest to where the breakdown occurs. However,
if you travel widely within the UK, you may wish
the wider cover of Option 2 which provides:
• Recovery of your car and up to seven passengers
to anywhere in the UK after a breakdown.
• A chauffeur if you are taken ill and there is
nobody else to drive home.
Option 3
European Breakdown and Accident
Assistance£53.00
If you are likely to be taking your car to the
European Union during the year, Option 3 offers
protection. The cover provided operates all year
round – no matter how many times you take your
car abroad! While travelling on the Continent, you
will be covered for:
• Emergency roadside repairs and towing
• Transport on to your destination
• Accommodation expenses while your car is
repaired (up to £45 per person per day, for 5
days) or
• Car hire costs for an equivalent vehicle (up to
£750) or
• Transportation of you, your passengers and
luggage back home
• The travel cost of transporting you to pick up
your repaired car (up to £600)
• Provision of a chauffeur when the only driver is
unable to drive because of illness or injury
• Sourcing and delivery of necessary spare parts
• Return of your car to the UK (up to its UK
market value)
• Legal expenses following a motoring accident
(up to £10,000)
• Advance of funds for bail or security
(up to £4,000)
Options 1, 2 and 3
only £79.50
If all three options are taken you will only have
to pay an additional £79.50.
All prices quoted are correct at time of printing
and include Insurance Premium Tax (IPT) at the
current rate.
Cover and premiums are subject to
individual assessment.
Conditions apply.
7
Premium payment options
You may choose between paying an Annual
Premium or using our Monthly Payment Plan.
You should pay Annual Premiums to your
insurance advisor. Please confirm acceptable forms
of payment directly with your advisor.
Monthly payments are collected from your Bank/
Building Society account by Direct Debit.
Monthly Payment Plan
Regulated by the Consumer Credit Act 1974
(APR 21.5%)
• To qualify?
You must be at least 20 years old and you must
have a Bank/Building Society account that
permits Direct Debits to be charged (if in doubt,
please check with your Bank/ Building Society).
• How does it work?
We will collect the first two monthly
premiums from your account by Direct
Debit immediately. Thereafter we will collect
your premiums at monthly intervals by Direct
Debit, commencing two months after the policy
is taken out. You will be notified of the amount
and date of all collections in writing before your
account is debited.
The Direct Debit system is carefully regulated by
the operating banks to make sure that YOUR
interests are always fully safeguarded – please
see the ‘Direct Debit Guarantee‘ overleaf.
• What about future premium changes?
If you alter your policy at any time your monthly
payment may change; in addition, the premium
required for your policy will be reviewed
annually. In either circumstance we will write
to you in advance informing you of any change
to the monthly payment amount required.
8
• How do I cancel my policy?
If you wish to cancel your policy simply give us
written notification and return your Motor
Certificate of Insurance, if applicable. Please also
inform your Bank/Building Society to cancel your
Direct Debit Instruction.
• What happens if Zurich does not receive
a Monthly Payment?
If your Bank or Building Society does not honour
any Direct Debit application, cover under your
policy will cease 7 days after the date we have
sent written notice to you. It is accordingly
very important that you notify us
immediately if you change your address or
move your bank account.
Monthly Payment Plan – what it costs
To work out the monthly premium all you have
to do is take the annual premium, add Insurance
Premium Tax at the current rate and then add
9% to it. Divide this figure by twelve to get the
monthly premium.
For example, if you want to convert an Annual
Premium of £347.21 to a Monthly Premium
it’s simply –
£347.21 Premium including IPT at current rate
£31.25
add 9% (instalment charge)
£378.46 Total annual premium
£31.54
÷12 = total monthly amount payable
To apply, please complete the Direct Debit
instruction enclosed and return it to your
insurance advisor or Zurich at the address
shown overleaf on the Direct Debit instruction.
Direct Debit instruction
Instruction to your Bank or Building Society to pay Direct Debits
Please complete parts 1-5 using a ball point pen
and send it to: Zurich Insurance, PO Box 458,
Cardiff CF10 5WY.
Originator’s identification number
7
6
3
8
6
4
4. Bank or Building Society account number
1. Name and full postal address of
Bank or Building Society Branch
Reference number
To the Manager
Bank or Building Society
Address
Postcode
2. Name(s) of account holder(s)
5. Instruction to your Bank or Building Society
Please pay Zurich Insurance Direct Debits
from the account detailed on this Instruction
subject to the safeguards assured by The Direct
Debit Guarantee.
I/we understand that this instruction may remain
with Zurich Insurance and if so, details will be
passed electronically to my Bank/Building Society.
Signatures of Account Holder(s)
3. Branch sort code (from the top
right-hand corner of your cheque)
—
—
Date
Banks and Building Societies may not accept Direct Debit Instructions for some types of account.
The Illustration below shows the information
needed from your cheque to complete the
direct debiting instruction
Bank or Building Society Address
(Please Quote Full Postal Address)
Name of
Account Holder
XYZ Bank PLC
06-20-41
15 High Street, Anytown AB2 3CD
Pay
Sort Code
20
Zurich Insurance
or order
£
JOHN SMITH
“807632”
Cheque Number
“062041”
“78432681”
Sort Code
Account Number
The direct debit guarantee
• This Guarantee is offered by all Banks and
Building Societies that take part in the Direct
Debit Scheme.
• If an error is made in the payment of your Direct
Debit, either by us, Zurich Insurance or by your
Bank or Building Society, you are entitled to a full
and immediate refund from your bank branch.
Simply contact your Bank or Building Society
to arrange a refund, or if you prefer contact
Zurich Insurance and they shall arrange to repay
you direct.
• You can cancel a Direct Debit at any time by
writing to your Bank or Building Society. Please also
send a copy of the letter to us.
• If there are any changes to the amount, date
or frequency of your Direct Debit, Zurich
Insurance will notify you in advance of your
account being debited, this will be 7 working
days or otherwise agreed.
• If you request us to collect a payment, confirmation
of the amount and date will be given to you at the
time of the request.
9
10
11
PL6/9154.19 (500431019) (02/14) RRD
Zurich Insurance plc
A public limited company incorporated in Ireland Registration No. 13460.
Registered Office: Zurich House, Ballsbridge Park, Dublin 4, Ireland.
UK Branch registered in England and Wales Registration No. BR7985.
UK Branch Head Office: The Zurich Centre, 3000 Parkway, Whiteley, Fareham,
Hampshire PO15 7JZ.
Authorised by the Central Bank of Ireland and subject to limited regulation by the Financial
Conduct Authority. Details about the extent of our regulation by the Financial Conduct
Authority are available from us on request. These details can be checked on the FCA’s
Financial Services Register via their website www.fca.org.uk or by contacting them on
0800 111 6768. Our FCA Firm Reference Number is 203093.
Communications may be monitored or recorded to improve our service and for security
and regulatory purposes.
© Copyright – Zurich Insurance plc 2014. All rights reserved. Reproduction, adaptation,
or translation without prior written permission is prohibited except as allowed under
copyright laws.
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the use of chlorine gas (ECF – Elemental Chlorine Free). The paper is suitable for recycling.