Car Solutions Insurance
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).
Policy Number (to be completed by Zurich)
Agents Reference Zurich Quote Reference
Proposer
Mr Mrs Miss Ms Dr Other (please give details)
1
First name(s) Surname
Address
Town
County Postcode
Occupation (including any part-time work and usual occupation if unemployed)
Nature of employers business (or your own if self-employed) Daytime telephone number (inc.STD code)
What is your marital status? (e.g. single/married/divorced/widowed)
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 RAC Green Flag Ltd Britannia Other Renewal month
Sex (please tick): Male Female
Age Date of birth
Car
2
#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.
1. Cover required from am / noon / pm 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 Car Park Other
4. Is your car fitted with a security system? Yes No
a) Alarm/immobiliser Yes No If ‘Yes’ state make and model
b) Tracking device Yes No If ‘Yes’ state make Make and model of car (e.g. Ford Escort LX)
cc Year Estimated value* Estimated annual mileage
Registration mark# Date of
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) Yes No
c) Wheels/suspension/brakes (e.g. alloy wheels, wide wheels, lowered suspension) 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 Yes No company vehicle?
If you have ticked any of the shaded boxes, please give full details.
History
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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
/ / / /
/ / / /
/ / / /
Drivers
3
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.)
Type of
Business or occupation UK or EC Period Do they Male or (full and part-time and usual licence (full licence own their Full name of driver Age female occupation if unemployed) Employers business or prov.) held own car
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 Cost
/ / £
/ / £
/ / £
Use
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14. In addition to social, domestic and pleasure (which permits travelling to and from work), will the car be used:
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? Yes No If yes, such persons must be named in Q.10.
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
6
15. Cover required Comprehensive Third party fire and theft Third party only
16. You may increase the standard £100* accidental £150 £200 £250 £350
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) 17. Driving Restriction
Yourself only Yourself and spouse Yourself and named drivers
(not available for Solutions Plus)
Yourself and one Yourself and two Any driver excluding drivers under 25
named driver named drivers (not available for Solutions Plus)
18. a) Are you claiming a No Claim Discount? Yes No
If you have ticked the shaded box attach insurer’s original renewal notice
and state number of years entitlement years
Options (comprehensive cover only in addition to our ‘inclusive’ Car Breakdown Cover)
7
19. Indicate which additional cover Option(s) you wish by ticking the appropriate box(es)
Home-Call Service £22.26 (included free Yes No
with Solutions Plus)
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.
Payment methods
8
20. Indicate by ticking one box how you wish to pay the premium – see full details on next page. Annually Monthly by Direct Debit
Important notes
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• 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
Declaration
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• 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.
A specimen copy of the policy is available on request Proposers signature
Date
Day Month Year
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.
Zurich Car Insurance
If you have selected our Solutions comprehensive cover you will automatically be provided with: 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.
Optional Covers
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:
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.
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.
• 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
Direct Debit instruction
Instruction to your Bank or Building Society to pay Direct Debits
— —
3. Branch sort code (from the top right-hand corner of your cheque) To the Manager
Bank or Building Society Address
Postcode
4. Bank or Building Society account number
Reference number
Originator’s identification number
7 6 3 8 6 4
Date
Signatures of Account Holder(s) Please complete parts 1-5 using a ball point pen
and send it to: Zurich Insurance, PO Box 458, Cardiff CF10 5WY.
1. Name and full postal address of Bank or Building Society Branch
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.
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)
Cheque Number Sort Code Account Number Name of
Account Holder XYZ Bank PLC
15 High Street, Anytown AB2 3CD
or order JOHN SMITH “807632” “062041” “78432681” 06-20-41 20
£
Sort CodePay Zurich Insurance
Banks and Building Societies may not accept Direct Debit Instructions for some types of account. 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.
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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