Abbeygate Motor Cyprus
Details of Proposer & Owner
Name     Date of Birth  
      Over 25  
      Over 30  
ID Number   Occupation  
Passport Num   Marital Status  
Passport Expiry   Resident in Cyprus  Yes No 
Address  
 
  (city)
  (province)
Telephone  
Email  
Nationality  
       Where did you hear about us ?  
 Licence Type      Years Licence Held  
 Years of NCB      Convictions Listed on Licence  
 Any Convictions Pending      Any Medical conditions that affect licence  
 Previous Insurer      Policy Number  
Vehicle details
Make    Model   
Registration    Engine size  
Age of Vehicle   Location  
Body Type   Drivers  
Drivers Age   Experience  
Claims and Convictions   Home policy with AIG?  
Other car insured with AIG   Vehicle Use  
Vehicle Value   Excess  
Fuel Type    Year of Manufacture   
When Purchased   Number of Seats  
Purchase Price   Country of Reg.  
Where car kept during day   Where car kept at night  
Towing a Trailer  Yes No  Cover for car stereo/audio (over Euro 150)  Yes No 
Does it have ABS  Yes No  Use of other vehicle  Yes No 
Does it have immobiliser/alarm  Yes No  Modifications  Yes No 
Payment terms
Payment Terms  Immediate    3 Monthly Instalments     Credit      Other   
Have you any other motor insurance with American Home? If yes, please state the policy numbers  
Have you a homeowners or business insurance with American Home ? If yes, please state the policy numbers  
Are you now, or have you ever been insured in respect of a motor vehicle, If yes, please state the policy number and insurance company  
Cover Required
Basic Cover  Third Party    TPFT    Comprehensive     Comprehensive (Wide)     Protect No Claims
Insurance Period From :    To :
 Start Time
Details of Vehicle
Are you the registered owner of the vehicle ?
If no, please state the name of the owner.
    Yes No 
Has the vehicle been bought under a hire purchase agreement ? If yes, please state the name of the financial institution      Yes  No
Are you the main user of the vehicle ?
If no, please state the name of the main user
     Yes  No
Is the vehicle kept at the above address when not in use ?
If no, please state the address at which its kept
     Yes  No
Is the vehicle in a good operating condition ?
If no, please explain.
     Yes  No
Has the vehicle been altered in any way from the makers standard specification ? If yes, please give details      Yes  No
Has the vehicle been imported second hand ?
If yes, please state country of origin
     Yes  No
If the vehicle has been imported second-hand, do you intend to register it in Cyprus?   N/A   Yes  No
Particulars of Other Drivers
Name
Date
of birth
Marital
Status
Sex Relationship
to proposer
Type of
driving licence
Date
obtained
Licence
number
Country
of issue
1. 
2. 
3. 
4. 
5. 
6. 
Declarations
to the best of your knowledge, have you or any person who will drive the vehicle..
ever been convicted of any criminal offence in connection with any motor vehicle or violation of traffic regulations or is any prosecution pending ?    Yes  No
Details :
I confirm all drivers are aged over 30 and under 70, have held a full UK/EU driving licence for at least 2 years, have no current convictions, and are free from claims or losses in the past 5 years
If no, give details :
During the last 3 years been penalised with penalty points inconnection with any violation of traffic regulations?    Yes  No
Had any damage or loss claim, wether to blame or not ?    Yes  No
Ever suffered during the last 3 years from diabetes, epilepsy, heart problems, reduced vision or hearing, or from any other disease or incapacity of the body or mind?    Yes  No
Details :
During the last three years been driving regularly and held the appropriate licence for the specific vehicle to be insured?    Yes  No
Details :
to the best of your knowledge, has any insurance company or any insurer at any time in connection with motor insurance for you or any person that will drive the vehicle...
Rejected any proposal for insurance ?    Yes  No
Refused to renew or cancelled any motor policy ?    Yes  No
Demanded increased premium or imposed special terms ?    Yes  No
Details :
Category and use of the vehicle
Private Vehicle: Is it going to be used for commercial and/or business purposes?    Yes  No
Commercial Vehicle : Is it going to transport own goods?    Yes  No
Commercial Vehicle : Is it going to draw a trailer?    Yes  No
Commercial Vehicle : If its a van with a passenger type body or a double cabin, is it to be used exclusively for social domestic and pleasure purposes, not for trade or business?    Yes  No
Commercial Vehicle : Is it going to transport general cartage?    Yes  No
Bus : Is it for private use?    Yes  No
Bus : Is it going to transport employees of the proposer?    Yes  No
Special Vehicle : Is it going to used for agricultural or forestery purposes?    Yes  No
Motorcycle : Is it for private use?    Yes  No
Motorcycle : Is it for commercial use?   Yes  No
Motor trade vehicle : Is it going to be used for private purposes by the named drivers?    Yes  No
Motor trade vehicle : Are they going to be driven for trial purposes by the intending purchaser accompanied by the proposer or his employee?    Yes  No
Motor trade vehicle : Are they going to be driven for trial purposes by the intending purchaser not accompanied by the proposer or his employee?    Yes  No