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Appendix C

Senior Managers’Vehicle Scheme

Motor Insurance Questionnaire


Address (inc. Postcode):

Date of Birth:


Make & model of vehicle:

CC and Value

Registration number and year of manufacturer

Details of security fitted

Where is the vehicle kept overnight: Garage / Driveway / Road

Do you wish driving to be restricted: Yes / No

If so: Insured Only / Insured and Partner / Four named drivers

Annual Mileage: 20,000 per annum

Current no claims discount (or number of years)

Have you or any person who to your knowledge who will drive:

(a)ever been disqualified from drivingYes / No

(b)been convicted during the past five years of any offence in

connection with any motor vehicleYes / No

(c)been convicted during the past five years of any offence relating

to theft, fraud or dishonestyYes / No

(d)any prosecution or police enquiry pendingYes / No

(e)had a proposal declinedYes / No

(f)been required to pay an increased premium or had special

terms imposedYes / No

(g)has a policy cancelled or been refused renewalYes / No

(h)had any accidents, damage, fire or theft losses during the past

five yearsYes / No

If “Yes” to a – h, please provide full details on a separate sheet, e.g. convictions, endorsements, offence, code, date, fine and period of disqualifications (if any).

In respect of accidents/incidents, please provide the following information:

Date of accident/incident:


Payments made for both own damage and third party damage:

Additional Drivers

Full Name / Date of Birth / Relationship to Manager
1st Additional
2nd Additional
3rd Additional
4th Additional


I hereby declare that to the best of my knowledge and belief the above statements and particulars are true and correct and that I have not withheld information material to this questionnaire whether the subject of a question or not. I agree to accept and conform to the terms of the policy when issued. I undertake that the vehicle to be insured shall not be driven by any person who to my knowledge has been refused any Motor Vehicle Insurance or continuance thereof. I consent to the seeking of information from other insurers to check the above details. I have provided, and I authorise the giving of such information for such purposes.

Important – All material facts must be disclosed. Failure to do so could invalidate the policy. A material fact is one likely to influence an Insurer in the assessment and acceptance of the proposal (e.g. any criminal conviction concerning dishonesty). If you are in doubt as to whether a fact is material then it should be disclosed to the Insurer.

Proposer’s Signature: ……………………………………………Date: ………………

Senior Managers Vehicle Scheme Rules