CALL 800 - NATURE (628873) | WE'RE ALWAYS HERE FOR YOU!

THIRD PARTY LIABILITY INSURANCE​ PROPOSAL FORM

Name of the Proposer










Insured's Estimated Value of the Vehicle without accessories:

Insured's Estimated Value of accessories:

List of accessories inside the motor vehicle:

Period of Insurance: From To
Type of Cover:

OPTIONS:(AT EXTRA PREMIUM)













ACCIDENT HISTORY:
How many accidents were you involved in over the last three years?
Of the above, how many were due to your fault?
Who were your previous insurers?