AUREOL INSURANCE COMPANY LIMITED
INCORPORATED IN SIERRA LEONE
KISSY HOUSE, 54 SIAKA STEVENS STREET, FREETOWN
Tel : +23278175175/+23233175175/+23288175175
Email : info@aureolinsurance.com
website : www.aureolinsurance.com
BRANCH OFFICE:
13 Tikonko Road
Bo
Tel: +232(79)175175
PROPOSAL FOR COMMERCIAL VEHICLE (HACKNEY CARRIAGE)
NAME OF PROPOSER IN FULL…………………………………………………………………………………………………………………….
(If an unlimited company or partnership include full names of all parties)
PROFESSION OR OCCUPATION………………………………………………………………………………………………………………….
ADDRESS……………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………...
TEL. NO………………………………………….FAX………………………………………….EMAIL……………………………………………
NAME IN WHICH THE POLICY IS TO BE ISSUED…………………………………………………………………………….…………………..
………………………………………………………………………………………………………………………………………………………...
TERM OF INSURANCE: FROM…………………….………………..20……….. . ..TO…….………………….…………...20……………
Maximum
Carrying Capacity Year
Index of Vehicles of Date Proposer’s Estimate
Mark Type Maker’s (I.e. Weight of Manu- of Price paid of present value in-
Make of each Vehicle & of Horse Cubic Load or Seating facture Purchase by cluding Accessories
Registra- Body Power Capacity Capacity Proposer thereon.
tion No. Including Driver)
(1)
(2)
(3)
(4)
2. State where Vehicle(s) is/are usually garaged .. .. .. ..
3. If more than one vehicle is to be insured, how many are garaged in the same building.. .. ..
4. (a) Are you the Owner of the Motor Vehicle(s) and is/are they registered in your name? .. (a) ___________________________________________________________
(b) If not, state name and address of Owner(s) and of the person(s) in whose name the
Vehicle(s) is/are registered.. .. .. .. .. .. .. .. .. (b) ___________________________________________________________
(c) Is a Hire Purchase Company interested or did you obtain a loan to purchase the
vehicle? .. .. .. .. .. .. .. .. .. .. (c) ___________________________________________________________
(d) If so, please give name and address of the Hire Company or the person from whom
the loan was obtained .. .. .. .. .. .. .. .. .. (d) ___________________________________________________________
5. Give full particulars of all purposes for which the Vehicle(s) will be used and general nature
of goods to be carried (if any) .. .. .. .. .. .. .. ..
6. (a) If used for Carriage of Goods, what is their general nature? .. .. .. .. (a) ___________________________________________________________
(b) Do you undertake, Cartage for other persons? .. .. .. .. .. .. (b) ___________________________________________________________
(c) Will any of the Vehicles be let out on hire? .. .. .. .. .. .. (c) ___________________________________________________________
(d) In respect of each Vehicle, state what Licence (I.e. A B or C) you hold .. .. .. (d) ___________________________________________________________
(e) Has the Vehicle been altered or adapted to carry a load heavier than stated in the
Makers’ published specification? .. .. .. .. .. .. .. .. (e) ___________________________________________________________
7. If used for carrying Passengers
(a) Are the Passengers carried for hire or reward? .. .. .. .. .. .. (a) —————————————————————————————–
(b) Are the Vehicles used for Public Service? .. .. .. .. .. ..
State Class of Licence, I.e. whether Stage, Hackney Carriage or other class (b) ___________________________________________________________
8. Are the Vehicles at present in a thorough state of repair? .. .. .. .. ..
9. Will the vehicle(s) be driven by (a) Proposer, (b) Paid Driver .. .. .. .. .. (a) ______________________________ (b) _________________________
10. Give name and driving license no. of driver .. .. .. .. .. .. .. (a) _____________________________ (b) _________________________

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

11. To the best of your knowledge and belief do you, or does any other person who to your knowledge
will drive, suffer from defective vision or hearing or from any physical infirmity? .. .. ..
12. Have you, or has any other person who to your knowledge will drive, been convicted during the
past five years of any offence in connection with any Motor Vehicle? .. .. .. ..
13. Total Number of Motor Vehicles owned by Proposer .. .. .. .. .. ..
14. Will a trailer or trailers be used/ If so, state number, carrying capacity, registration number and
value of each .. .. .. .. .. .. .. .. .. ..
15. State Town or Locality in which Vehicle(s) will generally be used .. .. .. ..
16. Are you now or have you been insured in respect of any Motor Vehicle?
If so, state name of Company or Underwriter .. .. .. .. .. .. ..
17. Has any company or Underwriter ever—(a) Declined you proposal?__________________________
(b) Required you to carry the first portion of any loss? _________________________________________ (d) Refused to renew your Policy?_____________________________
(c ) Required an increased premium or imposed special conditions? ___________________________ (d) Cancelled your Policy? ___________________________________
18. Give particulars of accidents or losses during past three years Damage to Proposer’
Motor Vehicle Third Party Others
Year Total number of Vehicles Total Number of
Owned by Proposer Accidents and Losses No. Amount No. Amount No. Amount
20 Paid
Outstanding
20 Paid
Outstanding
20 Paid
Outstanding
19. Are you entitled to a “No Claim Bonus” from your previous Insurers in respect of any of the
Vehicles described in this proposal? If so, please attach renewal notice .. ..
20. Do you wish to insure in respect of (a) Comprehensive Benefits or (b) Third Party Liability only,
or (c) Third Party Liability and Fire and Theft of the Vehicle(s), or (d) Act Liability only? ..
I/We warrant that the above statements and particulars are true and I/We have not suppressed or mis-stated any material fact and I/We hereby agree that
this Declaration shall be held to be promissory and shall form the basis of the contract between me/us and the AUREOL INSURANCE COMPANY LIMITED,
and I am/We are willing to accept a Policy subject to the conditions prescribed therein, and to pay the premiums thereon. I/We undertake that the Vehicle
or Vehicles to be Insured shall not be driven by any person who to my/our knowledge has been refused any Motor Vehicle Insurance or continuance thereof.
Date this………………………………………..day of…………………………………………………..20………………….
Agency………………………………………………………………………. Signature of Proposer……………………………………………………
NOTE: THE COMPANY RESERVES THE RIGHT TO DECLINE ANY PROPOSAL.