MOTOR INSURANCE PROPOSAL FORM

PLEASE ANSWER ALL QUESTIONS FULLY; WHERE QUESTIONS DO NOT APPLY, INSERT "N/A".

A. TYPE OF POLICY
1. Motor- Private ValueShield

B. PROPOSER INFORMATION (Photo Identification and Proof of Address if Proposer is an Individual)

2. Full Name: Mr GERALD ANDERSON
3. Date of Birth: 28 January 1985 4. Country of Birth: N/A 5. Nationality: Jamaican
6. Gender: Male 7. Marital Status: Married 8. TRN: 118985124
9. Home Address: 331 LIME PLACE BAMBOO DRIVE PORTMORE 10. Mailing Address: 331 PORTMORE PINES ST CATHERINE
PINES PORTMORE ST CATHERINE JAMAICA JAMAICA
11. Work/Business Address: 12. Email Address: geraldaandyson@gmail.com

BAMBOO DRIVE ST CATHERINE

JAMAICA

13. Phone #: Cellular Telephone - 8768168622

14. Type of ID: Driver's Licence 15. ID Number: 118985124 16. ID Expiry Date:
17. Occupation/Type of Business: (Describe in full and be specific; avoid vague terms like "Businessman", "Director")
Contractor

18. Name and Place of Employment: DYNAMIC BUILDERS CONSTRUCTION

19. Do you have any other type of insurance with JNGI? No If Yes, give details:

No
20. Have you or any relative or close associate been entrusted If Yes, give details:
with prominent public function (e.g. Politician, Senior
Government, Judicial or Security Force Officials) in any
country?
21. To the best of your knowledge, are you or any close relative No If Yes, give details:
(spouse, children, parents or siblings) connected in any way
(personal or business) to JNGI or any other member
company within the Jamaica National Group)?

C. VEHICLE DETAILS (Copies of Vehicle Documents are required)

22. Year: 2001
26. Reg. #: 3092JQ
30. Chassis #: CF41300108
32. Laden Weight: 2000 (Kg)
23. Make: Honda 24. Model: Torneo 25. Colour: BLUE
27. Body Type: Sedan 28. # of Seats: (incl. Driver) 5 29. Mileage:
31. Engine #: F20B2743000
33. Unladen Weight:
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34. Estimate of Value: $890000 35. Left or Right Hand Drive: Right Hand

36. Has the vehicle been or will it be modified from the No If Yes, give details:
Manufacturer's Specification to improve performance?
Yes
37. Are any Vehicle Tracking Devices attached? If Yes, give details:

D. COVER REQUIRED
38. Type of Cover Required: Third Party

39. Will you be driving the vehicle? Yes If No, name the Principal Driver:
40. Do you require cover for?
NB: Please complete a Driver Declaration Form for Principal Driver, Named Drivers or persons who will drive vehicle on a regular basis.
No
41. Do you require cover for towing (apart from towing a If Yes, give details:
disabled vehicle)? (e.g. towing a boat trailer)
Decreased
42. Do you require Increased Limits of Liability? If Yes, state the Option required:

43. Indicate if you require Increased Audio Windscreen Wrecker Manslaughter Personal
Limits for any of these Benefits? System Cover Fee Defence Accident
No No No No No
No
44. Are you earning No Claim Bonus/Discount from your If Yes, please provide proof.
previous Insurer?

E. PRIVATE MOTOR & PRIVATE COMMERCIAL VEHICLE USE

45. In addition to Private, Pleasure and for your Personal If Yes to any of these questions, please provide
Business Use, will the vehicle be used for: details.
(a) Your Employer's Business No

(b) Sales or Commercial Travelling No

(c) Carrying goods in connection with your or your

Employer's business No

(d) Carrying goods for hire or reward No

(e) Professional Driving Instruction No

(f) Hire Drive (Rental purposes) No

F. VEHICLE OWNERSHIP/MORTGAGEE/PREMIUM FINANCIER/SOURCE OF FUNDS

Yes
46. Is the vehicle registered in your name only? If No, please provide particulars of other
Owner(s).

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47. Do you have a financial interest in this vehicle? Yes If No, please provide particulars of other
Owner(s).
48. Does anyone else have a financial interest in No If Yes, please provide particulars of other
this vehicle? person(s)
49. Will anyone other than the registered owner(s) If Yes, please provide particulars of other
have custody and control of the vehicle? person(s)
50. Name and Address of Mortgagee Name and Address of Premium Financier
N/A

51. Source of Funds (used for paying the Insurance Premium):

G. PRINCIPAL DRIVER & OTHER DRIVER(S) INFORMATION, INSURANCE & ACCIDENT HISTORY
52. Provide the Name (s) of the Principal Driver, Named Driver(s) and Regular Drivers:
GERALD ANDERSON

NB: Please complete a Driver Declaration Form for the Principal Driver, Named Drivers and Regular Drivers.
53. Will anyone (including those named at question 83 If Yes, please provide details.
above), be driving who is/has:
(a) Less than 21 yrs old or over 80 yrs old (age 65
yrs for Public Passenger Vehicles) No

(b) A Provisional Licence No

(c)The appropriate Licence but for less than 1 year

No

(d) Had an accident, claim, conviction in the last 3

yrs
No

NB: You are required to declare to JNGI, the names of all known drivers (children, dependents or otherwise) who are less
than 21 years old or who have held their driving license for less than one year, prior to inception of the policy.

H. REFERENCES: (Applicable to Individual Proposers only)

I. DECLARATION OF THE PROPOSER

I/We warrant that:

- The above statements and particulars which I/We have read and checked are true
- I/We have not suppressed or misstated any fact
- The vehicle(s) referred to above is/are in good condition and repair

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I/We desire to effect insurance in accordance with the terms, conditions and exceptions of the Company's
standard policy. I/We agree
that this Proposal and any Declaration Form(s) completed by Other Driver(s) shall form the basis of the
Contract between me/us and
the Company and shall be deemed as incorporated in the policy to be issued.
I/We further declare and agree that if the above statements and particulars have been filled in by a person other
than the undersigned,
such person shall be deemed to be my/our Agent for the purpose of filling in this Proposal Form.
This document is generated from JNGI Online, and serves as proof of acceptance of our Terms and Conditions,
Privacy Policy, Refund
and Cancellation Policy, Delivery Policy and Flexi-Payment Agreement (if applicable).

Signature of Proposer: GERALD ANDERSON

Date: 01 September 2021
NB:
- At the inception of the insurance, your Policy may not be immediately available and so you may request a
Specimen of the Policy in addition to any Explanatory Notes.
- All outstanding premiums become payable in the event of an accident or any incident that may give rise to a
claim being made against this insurance.

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