Statement of Fact for Private Car Insurance

Agent’s Name Principal Insurance Limited Policy Number (if known) EPT110590002500
Address Citygate 2 Cross Street
Sale Broker Reference PRIN142499PC
Manchester Agency No 1059
M33 7JR Scheme Eridge Underwriting - Eridge Car

Your Details Please initial any alterations

Full Name Mr Michael Craig Rix Home Phone number 07453215337 Marital Status Single

Full Address Flat A, 3 Gorwydd Road Gender Male

Swansea
Glamorgan Children under No
SA4 3AG 18 years of age?
E-Mail address craigrix34@gmail.com
Residential Other Type of dwelling House Length of UK residency 38
status
Credit Cards No Are you a member of VAT registered No
held a Breakdown Service
Have you had a County Court Judgment registered against you in the past six years and/or defaulted on any credit agreement No
Cover
Cover to commence at 03:01:00 on 22/12/2023 For period of 12 months
Type of cover Comprehensive Use of the vehicle: Social, Domestic And Pleasure
Driving restriction Insured Only
Voluntary excess £1000 No claims Bonus Protection required (if available) No
Vehicle Details
Make and Precise
PEUGEOT 207 SPORT HDI (90) 207 SPORT HDI (90) Type of vehicle Hatchback
Model
Year of first Registration
Cubic Capacity 1560 Transmission Manual 2007 CV57CHD
registration number
Purchase price £600 Purchase date 01/10/2023 Estimated value £600 ABI/LMUA code 39061501
State if right or Right Hand Drive Type of fuel Diesel
Number of seats 5 Number of doors 3
left hand drive used
Current odometer Details of any security or tracking Unknown Alarm Vehicle Manufacturer 01/01/2007
reading devices fitted to the vehicle.
Estimated annual 3000
mileage
Vehicle owned by Proposer/Policyholder

Registered keeper Proposer/Policyholder

Has your vehicle been modified, altered or adapted in any way from the manufacturer’s standard specification, including any manufacturer or
No
dealer fitted options, whether or not performance is altered, or do you intend to alter it later? If ‘Yes’ provide full details.
NB Failure to disclose any modification could result in the policy being
declared invalid. If in doubt you should disclose it.
E.g. engine or body modifications, special or non-standard equipment,
non-standard or alloy wheels, cosmetic changes, sound systems
State the address at which the vehicle is Flat A, 3 Gorwydd Road, , Swansea, Glamorgan
normally kept
Where is the vehicle normally kept at night Garage Postcode at which the vehicle is kept during the day: SA4 3AG
Insurance History
Name of previous insurer Unlisted Insurer Policy number 0
Number of years No Claims Bonus 10 Expiry date 21/12/2023
Was your previous No Claims Bonus protected No Type of policy Private Car Bonus

Eridge Underwriting Agency Ltd are authorised and regulated by the Financial Conduct Authority. FCA Firm Reference Number 754644

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Give Details Below of All Persons Who Will Drive the Vehicle, Including Yourself (Drivers under 25 years of age must be disclosed)
Full name Mr Michael Craig Rix
Marital Status & Gender Single Male
Date of Birth & Age 19/04/1985 Age:38
Period resident in the U.K (Years) 38
Type of car driving license held Full UK Car Licence
Period car driving license held (Years) 20
Date car driving test passed 01/12/2003
Full time occupation (if unemployed state usual Security Guard
occupation)
Nature of employers’ business Security Services
Employment Status Employed
Part time occupation No
Nature of employers’ business (2nd Occupation)
Employment Status (2nd Occupation)
Relationship of this driver to the Proposer Proposer
Does this driver smoke? No
Does this driver drink alcohol? Yes
Nature of use of the vehicle for this driver Social, Domestic And
Pleasure
Does this driver own another vehicle? Yes
Does this driver have use of another vehicle? Yes
Estimated annual mileage of driver in this vehicle 3000
Is this driver the main user? Yes
Have you passed an advanced driver No If ‘Yes’ please advise which
qualification? qualification you have attained
Driving History
Have you or any person who may drive:
(a) been involved in any accident, claim or loss (including loss by fire, theft or malicious acts), irrespective of blame, during the past three years?
Note: Any loss should be disclosed whether or not a claim was submitted to the insurer concerned. If ‘Yes’, give details below. No
Name of Person Date of Circumstances of accident/loss Costs (£) NCD At fault?
accident/loss Affected
*

Mr Michael Craig Rix

* or would have had it not been for the operation of No Claims Discount Protection
(b) been convicted of any motoring offence, including Fixed Penalty offences, within the last five years or is there any prosecution pending? If ‘Yes’
please provide full details below. No
Name of person Date of Motoring Offence Alcohol Fine Penalty Disqualification
offence Code reading (if any) Points Period (if any)
Mr Michael Craig Rix

(c) been convicted of any other offence, including offence relating to theft, fraud or
dishonesty?
No

(d) any prosecution or police enquiry pending? No

(e) ever been disqualified from driving? No
(f) ever been declined or refused any type of insurance or had special terms imposed? No

Eridge Underwriting Agency Ltd are authorised and regulated by the Financial Conduct Authority. FCA Firm Reference Number 754644

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(g) Do you, or does any person who to your knowledge will drive have any history of defective vision not corrected by glasses or hearing not No
corrected by hearing aid, diabetic, epileptic, cardiac or alcoholic condition, or any disease or physical or mental infirmity or fits of any kind?
Name of Person Nature of Condition Date of onset DVLA Advised

Mr Michael Craig Rix

You are reminded that you are required by law to inform Driver Medical Branch, DVLA, Swansea, SA99 1AT, at once, if you have a disability (including any physical or mental condition) which is
or may become likely to affect your fitness as a driver.

Additional Information

We may share information which we hold and which has been supplied to us in connection with any application for insurance that you have made
or any insurance policy which you have with us with the Claims and Underwriting Exchange Register, run by Insurance Databases Services Ltd
(IDS Ltd), and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us check
information that is given to us and to prevent and detect fraudulent claims.

When we deal with your request for insurance, we may search the register(s). When you tell us about an incident which may or may not give
rise to a claim, we will pass information relating to it to the register(s). If we find that false or inaccurate information has been given to us, or we
suspect fraud, we will take appropriate action. If fraud is identified, details will be passed to fraud prevention and Law enforcement agencies.

We may also search your (or any person included on the proposal) Driving Licence Number against details held by the DVLA to confirm your
licence status, entitlement and restriction information and endorsement/conviction data. This helps insurers check information to prevent fraud
and reduce misrepresentation and non-disclosure.

We may research, collect and use data about you from publicly available sources including social media and networking sites, using this data for
the purposes of fraud detection and prevention.

You should show this notice to anyone who has an interest in the vehicles insured under the policy.

Full details of how your data is used and our Privacy Notice can be found on our website at www.eridgeunderwriting.com/the-eridge-
approach/privacy-notice/

Motor Insurance Database – Continuous Insurance Enforcement

Information relating to your policy will be added to the Motor Insurance Database (“MID”) managed by the Motor Insurance Bureau (“MIB”). MID
and the data stored on it may be used by certain statutory and/or authorised bodies including the Police, the DVLA, the DVANI, the Insurance
Fraud Bureau and other bodies permitted by law for purposes not limited to but including:

 Electronic Licensing.

 Continuous Insurance Enforcement.

 Law enforcement (prevention, detection, apprehension and/ or prosecution of offenders).

 The provision of government services and/or other services aimed at reducing the level and incidence of uninsured driving.

If you are involved in a road traffic accident (either in the UK, EEA or certain other territories), insurers and/or the MIB may search the MID to
obtain relevant information. Other persons (including their appointed representatives) pursuing a claim in respect of a road traffic accident
(including citizens of other countries) may also obtain information which is held on the MID.

It is vital that the MID holds your correct registration number. If it is incorrectly shown on MID, you are at risk of having your vehicle seized by the
Police. You can check that your correct registration number details are shown on the MID at ww.askmid.com.

DECLARATION I declare that the answers given above are true to the best of my knowledge and belief. I agree to accept the policy subject to
the terms, conditions and exceptions contained within. I also declare that if a third party (such as an insurance broker) has completed this form
on my behalf that I have checked that all of the questions have been answered correctly.
I understand that you will pass information I have provided on this form to the Motor Insurance Database (MID), the Claims and Underwriting
Exchange Register and the Motor Insurance Anti-Fraud and Theft register for the purposes described below and consent to the data transfer.
BEFORE SIGNING THIS FORM PLEASE READ NOTES BELOW.

IN THE EVENT OF A COMPLAINT: Eridge Underwriting Agency Ltd aim to provide a standard of service that will leave no cause for complaint.
However, if you are dissatisfied with the service we have provided please write to The Complaints Department, Eridge Underwriting Agency Ltd,
22-23 London Road, Tunbridge Wells, Kent TN1 1DA quoting your policy number or claims number and give us full details of you complaint.
If we are unable to resolve your complaint or are dissatisfied with your decision, you may have the right to refer your complaint to the Financial
Ombudsman Service. The Financial Ombudsman Service is an independent service in the UK for settling disputes between consumers and
Eridge Underwriting Agency Ltd are authorised and regulated by the Financial Conduct Authority. FCA Firm Reference Number 754644

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businesses providing financial services. You can find more information on the Financial Ombudsman Service at www.financial-
ombudsman.org.uk . the Financial Ombudsman Service, Exchange Tower, London E14 9SR. Tel: 0800 023 4567 or 0300 123 9 123; email:
complaints.info@financial-ombudsman.org.uk. Further details will be provided at the appropriate stage of the complaint process. This procedure
is without prejudice to your rights to take legal proceedings.

Eridge Underwriting Agency Ltd are authorised and regulated by the Financial Conduct Authority. FCA Firm Reference Number 754644

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