AUREOL INSURANCE COMPANY LIMITED
INCORPORATED IN SIERRA LEONE
KISSY HOUSE, 54 SIAKA STEVENS STREET, FREETOWN
Mobile : +23278175175/+23233175175/+23288175175
Email : info@aureolinsurance.com
website : www.aureolinsurance.com
BRANCH OFFICE:
17 Tikonko Road
Bo
Mobile: +232(79)175175
PROPOSAL FOR MOTOR VEHICLE INSURANCE
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……………
Year of Index Mark Seating Cost Whether Proposer’s
Make of Motor Car Manu- Cubic and capacity Type of Body Price Date of New or estimate of
facture Capacity Registration including When Purchase Secondhand approximate
Number Driver New (State price present value
paid by including
Proposer) Accessories
1.
2.
3.
State Engine and Chassis Engine No .. .. 1. 2. 3.
number of each car
Chassis No. .. .. 1. 2. 3.
2. Is the car at present in a thorough state of repair? Is it a Sports Model or Supercharged?
3. Will the Car (s) be driven by (a) Proposer? (b) Paid Driver? (c ) Anyone else?
4. Age next Birthday 5. State how long you have held a Driving Licence
6. To the best of your knowledge and belief do you or does any person who to your knowledge will drive suffer from defective vision or hearing or from
any physical infirmity?
7. (a) Are you the owner of the Car, and is it registered in your name?
(b) If not, state name and address of owners, and the name of the person in whose name the car is registered.
…………………………………………………………………………………………………………………………………………………………………………………………………...
(c) Is a Hire Purchase Company interested or did you obtain a loan to purchase the Vehicle?……………………………………………………………………………..
(d) If so, please give name and address of the Hire Company or the person from whom the loan was obtained.
…………………………………………………………………………………………………………………………………………………………………………………………………
8. (a) 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?
(b) If so, please give full particulars.
9. (a) Will the Motor Car be used otherwise than for social domestic and pleasure purposes?……………………………………………………………………………………
(b) If so, will the other use be
(I) In connection with the Motor Trade?………………………………………………………………………………………………………………………………………….
(ii) For the carriage of goods or samples?………………………………………………………………………………………………………………………………………..
(c) If the Motor Car has a private type of body has it been adapted or made adaptable for any use described in (b)…………………………………………………
(d) Will passengers be carried for hire or reward, or will the Motor Car be let on hire?……………………………………………………………………………………………
10. Are you now or have you been insured in respect of any Motor Vehicle?
If so, please state name of Company or Underwriter.

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

11. Has any Company or Underwriter ever-(a) Declined your 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? (e) Canceled your Policy?
12. Has any other person who will regularly drive the Car had any Motor Insurance declined, or had special terms or conditions imposed?
13. Please fill in below particulars of accidents or losses that have arisen during the last three years of actual driving in connection with this or any other
major vehicle owned or driven by you or by any other person who will regularly drive the car.
IT IS ESSENTIAL THAT THIS ITEM BE COMPLETED.
Total Number of
Motor Vehicles Total Number Claims by the Public for Personal Damage to Motor Vehicles Other Losses
owned by Proposer of Accident injury or damage to property
20 No. Paid Outstanding No. Paid Outstanding No. Paid Outstanding
20
20
14. Are you entitled to a “No Claim Bonus” from your previous Insurers in respect of any of the
Cars described in this Proposal? If so, please attach renewal notice.
15. Do you wish to insure in respect of (a) Comprehensive Benefits or (b) Third Party Liability only
or (c ) 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. I/We undertake that the Car or Cars to be insured shall not be driven by any person who to my/our knowledge has
been refused Motor Vehicle Insurance or continuance thereof 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 terms exceptions and conditions prescribed therein, and to pay the
Premium thereon.
Dated this……………………………day of…………………………………………20…………….
Signature of Proposer……………………………..
AGENCY/RELATIONSHIP OFFICER…………………………………………………….
NOTE: THE COMPANY RESERVES THE RIGHT TO DECLINE ANY PROPOSAL.