MOTOR VEHICLE INSURANCE APPLICATION FORM

A. THE APPLICANT’S INFORMATION(If the applicant is the vehicle owner, no need fill in this section)
Name: / ID/ Business license No.:
Address: / Tel/Fax:
B. THE MOTOR VEHICLEOWNER’S INFORMATION
Name: / ID/ Business license No.:
Address: / Tel/Fax:
C. BENEFICIARY ’S INFORMATION
Name: / ID/ Business license No.:
Address: / Tel/Fax:
D. INFORMATION OF THE MOTOR VEHICLE TO BE COVERED
Registration No.: / Engine No: / Chassis No.: / Number of Seats:
Trade name: / Model: / Year of Manufacturing/ registration:/ / Tonnage:
Type: / Passenger cars
Cargo truck / Money trucks
 Taxi / Other Specialized vehicle
Specialized motorbike / Bus
Ambulance / Pickup, minivan
Trailer-tractors / Cars for driving practice
Other:
Using purpose: Commercial  Non-Commercial / History of loss:1yearno loss
2 consecutive years no loss
3 consecutive years no loss
Yes, amount:……………………………
The additional equipment installed on the vehicle: NoYes, pleaseattached list
Market value:
E. INSURANCE PERIOD
From: / To:
F. TYPE OF INSURANCE, COVERAGE, SUM INSURED
1.  / Physical damage insurance (total)
 New replacement value
 Approved repairers
 Damage to the engine caused by water
 Theft insurance to partial loss of motor vehicle
 Others:...... / - Sum insured...... VND
- Deductible:  500.000VND  1.000.000VND  Khác: ……VND
2.  / Personal accident insurance for drivers, driver assistant and passengers / - Number of the insured: …………….. persons
- Sum insured:...... million VND/person/Occ.
3.  / Civil liability insurance of the motor vehicle owner against the goods carried / - Sum insured:...... million VND/Ton
4.  / Compulsory civil liability insurance / - For person: 100million VND/person/Occ.
-For property: 100million VND/Occ.
5.  / Voluntary civil liability insurance / -Forperson: ………………………………. million VND/person/Occ.
- Forproperty: ……………………………… million VND/Occ.
G. Payment mode / H. Language of the policy
Bank transfer / Cash Other:……………………………………….. / EnglishVietnamese
I. Declaration
(1) We hereby declare that the statements made by us in the Application Form are complete and true to the best of our knowledge and belief, and we hereby agree that this Application Form shall form the basis and be part of any Policy of Policies issued in connection with the above risk or risks.The Insured undertakes to inform the Insurers of any material alteration whereby the risk is increased, and the Insurers reserve the right to modify any quotation made in the light of such alteration.
(2)According to Item a Clause 2 Article 19 of Law on Insurance Business: “An insurer shall have the right to suspend unilaterally the implementation of an insurance contract and to collect the insurance premium up until the time of suspension of implementation of the insurance contract, upon one of the following acts being committed by the purchases of insurance:
a) Intentionally providing false information with the aim of entering into an insurance contract in order to be paid insurance proceeds indemnity;”
(3)The Insurance Policy is valid subject to the Insurer’s agreement.
______
Date (dd/mm/yyyy)Signature (and/or stamp)

1/2