Freeman Mcmurrick Quotation & Proposal Securus Motor Insurance Page 5
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7Made a claim on any motor insurance policy?
Yes
No
Suffered a loss or damage to a motor vehicle for which you did not claim or were not insured for?
Yes
No
If you have answered “Yes” to either question please describe the circumstances below.
Details of loss
Drivers name
Person at fault
Cost
Date of loss
Insurer
Details of loss
Drivers name
Person at fault
Cost
Date of loss
Insurer
Details of loss
Drivers name
Person at fault
Cost
Date of loss
Insurer
Details of loss
Drivers name
Person at fault
Cost
Date of loss
Insurer
Suffer from any illness or disability, likely to affect driving/riding ability?
Yes
No
If yes, please provide details.
Had any claims refused, insurance policy declined, cancelled or had special terms imposed?
Yes
No
If yes, please provide details.
Declared bankrupt and not discharged within the last 12 months, or currently involved in bankruptcy
or repossession proceedings?
Yes
No
If yes, please provide details.
In the last 10 years, been convicted of, or had any fines or penalties imposed for any crime involving drugs,
dishonesty, arson, theft, fraud or violence against any person or property?
Yes
No
If yes, please provide details.
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