Insurance Proposal Form Dec2016 Dec17 Group (1) .pdf

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P&K Ternent t/a NORTHUMBRIA CLASSIC CAR HIRE
SELF DRIVE CLASSIC CAR HIRE DRIVER PROPOSAL FORM & HIRE AGREEMENT
underwritten by Highway Insurance Company Limited
Certificate Number : FLT / 100179 / FCV / 1000710693 / 01DEC16 / 3203
To be completed by the Hirer BLOCK CAPITALS PLEASE – PLEASE COMPLETE ALL PAGES
HIRER DETAILS- Hirer is person providing ID and credit/debit card details & is responsible for vehicle & all costs
Title
(Mr/Mrs/Ms)

First Names

Surname

Permanent Home Address

Postcode
Home Telephone

Mobile

Work Telephone

Email

I intend to use the vehicle for social
domestic and pleasure purposes
only.

YES / NO

If you require the vehicle
for business purposes
please state intended use

Will the vehicle be used outside the United Kingdom?

YES / NO

If YES details of foreign use – YOU MUST NOTIFY US IN ADVANCE IF YOU INTEND TO USE OUR VEHICLE ABROAD

Make & Model
GROUP DRIVE

PERIOD OF HIRE
From

c.c.

am/pm

Year of Make

On (DD/MM/YY)

AGREED HIRE RATE FOR ABOVE PERIOD

To

£

Registration Mark

am/pm

On (DD/MM/YY)

EXCESS £1000

You are reminded of the need to disclose any fact which the insurers would take into account in the assessment and acceptance of the proposal. If you have
any doubt as to whether certain facts are relevant please consult the Self Drive Operator.
It is an offence under the Road Traffic Acts to make any false statement or withhold any material information for the purpose of obtaining motor insurance.
1984 Data Protection Act
Insurers maintain a motor insurance anti-fraud and theft register. In line with the 1984 Data Protection Act’s first data protection principal, which is concerned
with ‘the obtaining of information’, we wish to advise you that insurers exchange information with each other to detect fraudulent claims.
I agree that whilst rental agreement is in force, I will be liable as the hirer for this vehicle or any replacement vehicle provided, for any fixed penalty notice,
congestion charge, or parking fines acquired for that vehicle under S66 Road Traffic Offenders Act 1988 and Schedule 6 Road Traffic Act 1991.
Declaration
I declare that all statements and particulars given by me in this proposal, which I have read over, are correct and that no material fact has been omitted, misrepresented or mis-stated. I am not aware of any other circumstances that are likely to affect the risk. I agree that this proposal is subject to English law.

P & K Ternent t/a Northumbria Classic Car Hire – 17 Linden Road, Newcastle- NE3 4EY- 0191 406 3527info@northumbriaclassics.com- www.northumbriaclassics.com

I undertake that I shall not allow the vehicle to be driven by any person not authorised to drive the vehicle during the period of hire.
Important
It is important that you have read and understood the terms and conditions that will apply to this contract before signing. Only sign this agreement if you wish
to be bound by the terms and conditions provided and that you confirm that by making payment by credit/debit card, your signature is authority to collect any
amount you owe.
A deposit will be required on the day of hire for security and insurance cover of £500-2250. This will be taken by pre authorising a credit/debit card, the amount
of deposit is not taken by us but is “frozen” in your account by your bank until it is cancelled by us on return of the car in good condition. Some banks can
take up to 10 days to release the money back into your account, we are not in control of this, we will cancel the transaction immediately on return of the car
within the hire period in good condition and full of fuel.
If the car is returned later than the agreed return time we will automatically charge your credit card £50 so we can arrange additional insurance cover for you.
If you return the car without the correct amount of fuel we will automatically charge your credit card £50.
LV= and Liverpool Victoria are registered trade marks of Liverpool Victoria Friendly Society Limited and LV= and LV= Liverpool Victoria are trading styles of
the Liverpool Victoria Group of Companies. Underwritten by Highway Insurance Company Limited, part of the Liverpool Victoria group of companies. Highway
Insurance Company Limited, registered in England and Wales number 3232514, is authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority register number 202965. Registered address for both companies: County Gates,
Bournemouth BH1 2NF.
NOTE*** Please read attached Endorsement schedule (LV insurance FCV /1000710693) – your signing below confirms that you or the extra drivers are not
amongst the “excluded persons listed in section 2 a)-j)

Signature of Hirer

Date

*** “I further agree to be bound by the terms and conditions of the insurance which I have seen and read or have
had the opportunity to see and read”

MAIN DRIVER 1 DETAILS *(For completion only if Main Driver is different to Hirer) THIS INFO REQUIRED IN ALL CASES**
* Title
(Mr/Mrs/Ms

* First Names

**Surname

* Permanent Home Address

* Postcode

* Email

* Home
Telephone

Drivers Occupation
**

* Work Telephone

Age**

* Mobile

Date of Birth**

*Licence number

*NI number

Have You:

P & K Ternent t/a Northumbria Classic Car Hire – 17 Linden Road, Newcastle- NE3 4EY- 0191 406 3527info@northumbriaclassics.com- www.northumbriaclassics.com

YES or NO

(a)

Been involved in a motoring accident or loss in the last 3 years - Give details at (a) below
Please ring if you have more than 2 accident or loss claims within the last 3 years regardless of fault

YES / NO

(b)

Sustained any driving convictions or endorsements on your licence within the last 5 years (i.e, speeding
convictions,)? LIST ALL CONVICTIONS , including SP30’s SP50’s etc at (b) below
NOTE - Please ring if you have convictions commencing with:
BA
Disqualified driver
CD
Careless Driving
DD
Dangerous Driving
DR
Drink / Drug Driving
TT
Disqualification through totting up points
UT
Theft or unauthorised taking of a vehicle
XX
Disqualification through totting up points
As an additional security deposit may be required

YES / NO

(c)

Had any motor insurance proposal declined or has any insurer not invited renewal or refused to renew or
cancelled a policy or imposed special conditions (e.g. premium loading, cover restrictions or stipulated that the
first part of any loss should be borne?)

YES / NO

(d)

Have any disabilities or medical conditions which have needed to be notified to the DVLA?

YES / NO

If you have answered YES to any of (a) to (d) above, please give details.
(a)
(b)
(c)
(d)

I confirm that I have held a full UK / EU Driving licence for more than 2 years applicable to the type of vehicle being
hired

YES / NO

If you hold a non UK/ EU driving licence please notify us immediately

Date

Signature of Driver 1

ADDITIONAL DRIVER 2 DETAILS
Title (Mr/Mrs/Ms

First Name

Surname

Permanent Home Address

Postcode

Drivers Occupation

Home Telephone

Mobile

Work Telephone

Email

P & K Ternent t/a Northumbria Classic Car Hire – 17 Linden Road, Newcastle- NE3 4EY- 0191 406 3527info@northumbriaclassics.com- www.northumbriaclassics.com

Age

Date of Birth

*Licence number

*NI number

Have You:

YES or NO

(a)

Been involved in a motoring accident or loss in the last 3 years - Give details at (a) below
Please ring if you have more than 2 accident or loss claims within the last 3 years regardless of fault

YES / NO

(b)

Sustained any driving convictions or endorsements on your licence within the last 5 years (i.e, speeding
convictions,)? LIST ALL CONVICTIONS , including SP30’s SP50’s etc at (b) below
NOTE - Please ring if you have convictions commencing with:
BA
Disqualified driver
CD
Careless Driving
DD
Dangerous Driving
DR
Drink / Drug Driving
TT
Disqualification through totting up points
UT
Theft or unauthorised taking of a vehicle
XX
Disqualification through totting up points
As an additional security deposit may be required

YES / NO

(c)

Had any motor insurance proposal declined or has any insurer not invited renewal or refused to renew or
cancelled a policy or imposed special conditions (e.g. premium loading, cover restrictions or stipulated
that the first part of any loss should be borne?)

YES / NO

(d)

Have any disabilities or medical conditions which have needed to be notified to the DVLA?

YES / NO

If you have answered YES to any of (a) to (d) above, please give details.

(a)
(b)
(c)
(d)

I confirm that I have held a full UK / EU Driving licence for more than 2 years applicable to the type of
vehicle being hired

YES / NO

If you hold a non UK/ EU driving licence please notify us immediately

Signature of Driver 2

Date

*** “I further agree to be bound by the terms and conditions of the insurance which I have
seen and read or have had the opportunity to see and read”

P & K Ternent t/a Northumbria Classic Car Hire – 17 Linden Road, Newcastle- NE3 4EY- 0191 406 3527info@northumbriaclassics.com- www.northumbriaclassics.com


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