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ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan 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Add Vehicle Maximum number of vehicles reached. List your Underwriting InformationHiddenUnderwriting InformationHave any driver been declined insurance in the last 12 months?* Yes No Has any driver had a criminal conviction in the last 5 years?* Yes No Has any driver had a claim, accident, car stolen or burnt (even if not reported or not claimed from an insurer)?* Yes No Have any drivers had their vehicle or motorcycle licences cancelled or suspended?* Yes No If yes to any of the above, please provide detailsPrivacyWe are committed to protecting your privacy. We use the information you provide to us to arrange for and quote on the financial services we provide to you. We only provide personal information to the financial service providers (and their representatives) and those appointed to assist you with claims under policies of insurance. We will not trade, rent, or sell the information.If you do not provide us with full information, we cannot properly quote / arrange your financial products and provide the service you expect. You can check the personal information we hold about you at any time. For more information about our Privacy Policy Statement, ask us for a copy.Duty of DisclosureThe law requires you to tell us everything you know (or could reasonably be expected to know in the circumstances) which is relevant to our decision to insure you and the terms on which we insure you. This duty applies before you enter into a contract with us, that is, before we accept your proposal and also each time before you alter or renew the Policy. Each person named as the Insured has the same duty.Penalty for Non-DisclosureIf you do not tell us everything necessary, we may: reduce or refuse to pay a claim; or cancel your Policy. If you act dishonestly, we may invalidate the Policy from its beginning and not be bound by it.You don’t need to tell us anything which: reduces the risk; is common knowledge; we already know or ought to know in the ordinary course of our business; or we indicate we do not want to know. If you are not sure that something is relevant, it is best to disclose it anyway.Declaration and Signature The Duty of Disclosure, Non-Disclosure and Inadequate Space to Answer notices set out above have been read by me/us. All answers and statements made in this application are true and accurate in every respect and no information has been withheld which is likely to affect your decision about accepting this insurance. I acknowledge you reserve the right to decline any application. 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