CARROT CAR INSURANCE - STATEMENT OF FACT IMPORTANT – PLEASE READ CAREFULLY Please read the following information carefully. It is a record of statements made and information given by you and which we have taken into account in entering into this insurance contract. WARNING: You must take reasonable care to ensure you have answered all questions fully and accurately. You must tell us immediately if any of the information on which this insurance is based is incorrect, or changes. If you are satisfied that you have answered all questions fully and accurately, you need take no further action, simply retain the form in a safe place along with your policy and Certificate of Insurance. If any of the following details appear to be incomplete or incorrect please contact 0333 355 1725 within the next seven days. Failure to do so could result in your insurance no longer being valid and claims not being paid or not being paid in full. You will be advised of any changes in the premium or terms and a revised Statement will be issued to you.
1. YOUR DETAILS
If No to questions b, c, d below give details overleaf
Title
Mr
a) Marital Status?
Surname
Cyruk
b) Are you the legal owner of the vehicle?
YES
First Names
Adrian
c) Is the vehicle registered in your name?
YES
d) Are you the main user/driver of the vehicle? e) Do you own or have use of any other vehicle (e.g. company car)? f) Type of motor vehicle licence currently held
Contact Details 71 Burton Street South Elmsall Pontefract
Address
WF9 2AH
Dwelling Type (e.g. house, flat, caravan etc)
Daytime Phone No.
07417591342
E-mail address
[email protected]
Date of Birth
20/03/1993
YES NO Full EU Licence
g) State if Full or Provisional
Full
h) State date obtained
02/01/2013
i) Date of Residency in the UK
20/03/1993
House
Occupation Type Postcode at which the vehicle kept overnight 1st Occupation
Married
WF9 2AH 2nd Occupation
Customer Advisor
Fulltime / Part time
Fulltime / Part time
State Nature of Business Employment Status (employed, unemployed, self-employed etc)
Retailing
State Nature of Business Employment Status (employed, unemployed, self-employed etc)
Employed
2. COVER INFORMATION To commence on Cover required:
26/02/2016 15:55:00 Comprehensive
for a period of 12 months. Amount of Voluntary Excess Required :
This will apply in addition to any policy or young/inexperienced driver excess.
£250
3. WHO WILL DRIVE? Drivers allowed to driver the vehicle
Insured And 1 Named Driver
4. DRIVER DETAILS Please give details of all persons to be insured to drive other than yourself. NAME
Date of Birth
Relationship to Proposer
Mrs Anita Solosciuk
26/06/1993
Spouse
NOTE: The Premium will be calculated on the highest rated driver.
Date of Residency in UK
Occupation (including any part time jobs)
Nature of Business
Employment Status (employed, unemployed etc)
01/06/2010
Warehouseman
Clothing Trade
Employed
Type of motor vehicle licence Full or Provisional & period held TYPE Date Full or Licence Type Obtained Provisional Full EU Licence
State whether you or any person who may drive:a) Now has, or has ever had, any physical handicap or infirmity, any diabetic, heart, circulatory, epileptic, mental or alcohol condition, impaired sight or hearing? b) Has been convicted of any motoring offence (including fixed penalty offence) or had a licence endorsement during the last 5 years? c) Has any police enquiry or prosecution pending? (Note – if you have been stopped by the police a prosecution may be pending and must be disclosed) d) Has been convicted of any non-motoring offence? e) Has been disqualified from holding or obtaining a driving licence? f) Has been involved in any accident, theft, attempted theft or malicious damage, or sustained any loss in connection with any motor vehicle in the past five years, whether covered by insurance or not? g) Has been refused insurance at normal terms or had a motor policy cancelled?
Full
NO NO NO NO NO NO
01/01/2013
If the answer to any of the questions is YES please give details overleaf
NO
5. VEHICLE DETAILS Make HONDA
Model (including model number) ACCORD
Body Type/No Seats Saloon / 5
Registration Number OE03NPZ
Year 2003
Fuel Type Petrol
Trans-mission Manual
a) Has the motor vehicle been modified to change the maker’s standard specification or alter its performance? This includes cosmetic changes e.g. body kits, alloy wheels, spoilers, side skirts and any optional extras including LPG conversions. If yes please provide full details overleaf Security Device Make & Model
Security Device Installer
Unknown Combined Alarm/Immobiliser
Insurer Approved Fitter
c) vehicle registration thatIfityes, has please been imported a country outside the EU? b) Does Is the the motor vehicle fitted withdocument a securityshow device? provide from full details below d) Overnight garaging facilities? (e.g. garage, driveway, car park, road etc) e) Is the vehicle left or right hand drive (driving position)?
Engine Size 1998
NO
YES
Proposer’s Estimated Value 1195.00
Date of Purchase
Current Mileage Fitted Date Annual Mileage Limit
01/01/2016
Estimated annual mileage 8000
0 Certificate Attached? 8000
You may qualify for a low mileage discount. Please state current Milometer reading and annual limit Parked On Drive NO
Right
Carrot Insurance is a trading style of Carrot Risk Technologies Limited. Carrot Risk Technologies are authorised and regulated by the Financial Conduct Authority (FCA) under firm reference number 610895. Carrot Risk Technologies Limited, company number 07771243 registered in England and Wales. Registered address: Global House, Westmere Drive, Crewe Business Park, Crewe, CW1 6ZD.
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6. USE Driver name
Use Required Commuting incl Social, Domestic and Pleasure Commuting incl Social, Domestic and Pleasure
Adrian Cyruk Anita Solosciuk
7. NO CLAIM DISCOUNT Indicate number of years’ entitlement for the car to be insured and attach previous insurer’s renewal notice. Previous Insurer
3 years
Do you wish to protect your NCD (available for all covers but subject to qualifying conditions)
Previous Policy No.
Unknown
Previous Policy Expiry Date
1010101
NO
02/02/2016
8. ADDITIONAL INFORMATION VEHICLE OWNERSHIP – Legal owner, registered keeper, main driver If Owner/Keeper/main user is not proposer, please provide full details Registered Proposer/Policyholder Registered Keeper Owner DISABILITIES/PHYSICAL CONDITION – Driver’s name, nature of condition, date diagnosed, any restriction on licence Driver Name Medical Condition DVLA Notified?
Proposer/Policyholder Licence Issued
Date Diagnosed
CONVICTIONS/PROSECUTIONS/NON-MOTORING OFFENCES – Driver’s name, convictions Driver Name
Offence Code
Offence Date
Points
Disqualified
Date Disqualified
Period (months)
ACCIDENT/LOSSES – Driver’s name, circumstances, date, costs, etc. Driver Name
Date
Claim Type
Claim Status
NCD Prejudiced
At Fault
Cost (£)
MOTOR VEHICLE MODIFICATIONS Modification Type
Modification Value (£)
Modification Type
Modification Value (£)
ANY OTHER DETAILS
DECLARATION By accepting this Statement of Fact as a true and complete record of the information relevant to this application for insurance you confirm that: (a) (b) (c) (d)
the answers given are true and to the best of your knowledge and belief, and I/We agree that if any answer has been written by any other person he/she shall for that purpose be regarded as my agent and not the agent of the insurer I/We understand that if I elect to pay premiums monthly, the liability of the insurer will cease in the event of non-payment of any monthly premium on its due date but I will always be given 7 days written notice before cancellation takes effect. I/We have read the Important Notes section and I/We understand how the policy data may be used and have informed other parties related to this insurance accordingly.
You agree to accept a policy booklet in the current form issued by the insurers subject to the terms and conditions and limitations contained therein and you agree to pay the premium. You understand that we will pass the information on this form and about any incident you may give details of to IDS Ltd and the ABI so that they can make it available to other insurers. You also understand and accept that, in response to any searches we may make in connection with this application or any incident you have given details of, IDS Ltd and the ABI may pass us information it has received from other insurers about other incidents anyone insured to drive the vehicles covered under the policy has been involved in.
NOTES CONCERNING THIS APPLICATION FOR INSURANCE 1. 2. 3. 4. 5. 6. 7.
No liability (except for the period stated on our official Cover Note) is undertaken until the application is accepted by ourselves and the premium paid. We reserve the right to ask for special terms or decline this application. If we decline this application a premium will be payable by you for the period in the official Cover Note. You should keep a record (including copies of letters) of all information supplied for the purpose of entering into this insurance. We will supply a copy of this Statement of Fact on request within three months of completion. For our joint protection, telephone calls may be recorded and/or monitored. A Specimen copy of the policy is available upon request. The complaints procedure and a summary of the policy terms and conditions are contained in the separate Policy Summary document, a copy of which is available from your insurance intermediary.
Carrot Insurance is a trading style of Carrot Risk Technologies Limited. Carrot Risk Technologies are authorised and regulated by the Financial Conduct Authority (FCA) under firm reference number 610895. Carrot Risk Technologies Limited, company number 07771243 registered in England and Wales. Registered address: Global House, Westmere Drive, Crewe Business Park, Crewe, CW1 6ZD.
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IMPORTANT NOTES CANCELLATION You have the right to cancel this policy at any time. You must return the current Certificate of Motor Insurance before cancellation can be effected. You will, for a period of 14 days from the date you receive your Policy documentation, have a right to cancel this policy and receive a refund (unless you have made a total loss claim). This refund will be subject to a charge for the period of cover you have received, plus a cancellation charge of up to £150 (including Insurance Premium Tax) . However where cover has not commenced prior to the end of this 14 day period, you will be entitled to a full refund of the premium you have paid. To exercise your right to cancel please contact Carrot Insurance. Beyond the 14 day period, you will still be entitled to cancel this policy and provided there have been no claims in the current period of insurance we will refund the premium relating to the number of days remaining during the current period of insurance on a pro rata basis, less a cancellation charge of £150 (including Insurance Premium Tax). The insurer’s cancellation charge may be in addition to any cancellation charge levied by Carrot Insurance. Your insurer may also cancel the policy by giving you seven days written notice. In the event of cancellation by the insurer the cancellation charges stated above will apply. For full details of the cancellation process, please refer to Condition 5 in the policy booklet.
DATA PROTECTION Carrot Insurance and the insurer shown in your schedule hold your personal information in accordance with the Data Protection Act 1998. The information supplied to us by you may be held on computer and passed to other insurers and re-insurers for underwriting and claims purposes. You should show this notice to anyone whose personal information may be processed to administer this policy, including handling any claims. We use a variety of security technologies and procedures to help protect your information from inappropriate use, and we will continue to revise procedures and implement additional security features as new technology becomes available. Your insurer may use your information for underwriting purposes, statistical analysis, management information, market research, testing to ensure the integrity of their systems, and risk management. Your information will only be shared as described in this notice, or where we are required or allowed to do so by law.
INSURANCE ADMINISTRATION Information you supply may be used for the purposes of insurance administration by Carrot Insurance, the insurer shown on your schedule, their group companies, business partners or agents or by re-insurers. This may include companies inside and outside the European Economic Area. If your personal information is transferred it will be appropriately protected. In assessing any claims made, insurers may undertake checks against publicly available information such as electoral roll, county court judgment, bankruptcy or repossessions. Information may also be shared with other insurers either directly or via those acting for the insurer such as loss adjusters or investigators.
INFORMATION ON PRODUCTS & SERVICES We may use your details to send you information about other products and services from Carrot Insurance or to carry out research. We may contact you by letter, telephone or email. Please be reassured that we won’t make your personal details available to any companies outside Carrot Insurance to use for their own marketing purposes. If you would prefer not to receive information from us or participate in research, simply write to Data Protection Officer, Carrot Insurance, Global House, Westmere Drive, Crewe Business Park, CW1 6ZD.
EXCHANGING INFORMATION WITH OTHER INSURERS Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell us about an incident (such as a fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask us for more information about this.
MOTOR INSURANCE DATA BASE Your policy details will be added to the Motor Insurance Database (MID) run by the Motor Insurers Information Centre (MIIC). This may be consulted by the police in order to establish who is insured to drive the vehicle. If you are involved in an accident (in the UK or abroad) , other UK Insurers, the Motor Insurer’s Bureau and MIIC may search the MID to ascertain relevant policy information. Persons with a valid claim in respect of a road traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID. You can find out more about this from us by calling 0333 355 1725 or at www.MIIC.org.uk.
FRAUD PREVENTION, DETECTION & CLAIMS HISTORY In order to prevent and detect fraud we may at any time:
Share information about you with the police, fraud prevention and detection agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this. We and other organisations may also search these agencies and databases to: Help make decisions about the provision and administration of insurance, credit and related services for you and members of your household; Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your accounts or insurance policies; Check your identity to prevent money laundering, unless you furnish us with other satisfactory proof of identity;
Undertake credit searches and additional fraud searches (this may include requests for copy driving licences, utility bills and other documentation to establish the identity of any person applying for insurance).
We can supply on request further details of the databases we access or contribute to.
CLAIMS HISTORY
Under the conditions of your policy you must tell us about any Insurance related incidents (such as fire, water damage, theft or an accident) whether or not they give rise to a claim. When you tell us about an incident we will pass information relating to it to a database.
We and other insurers may search these databases when you apply for insurance, in the event of any incident or claim, or at time of renewal to validate your claims history or that of any other person or property likely to be involved in the policy or claim.
CREDIT SEARCHES AND ACCOUNTING In assessing your application/renewal, we may search files made available to us by credit reference agencies. They keep a record of that search. We may also pass to credit reference agencies information we hold about you and your payment record with us. Credit reference agencies share information with other organisations, enabling applications for financial products to be assessed or to assist the tracing of debtors, or to prevent fraud. We may ask credit reference agencies to provide a credit scoring computation. Credit scoring uses a number of factors to work out risks involved in any application. A score is given to each factor and a total score obtained. Where automatic credit scoring computations are used by us, acceptance or rejection of your application will not depend only on the results of the credit scoring process.
SENSITIVE DATA
Carrot Insurance is a trading style of Carrot Risk Technologies Limited. Carrot Risk Technologies are authorised and regulated by the Financial Conduct Authority (FCA) under firm reference number 610895. Carrot Risk Technologies Limited, company number 07771243 registered in England and Wales. Registered address: Global House, Westmere Drive, Crewe Business Park, Crewe, CW1 6ZD.
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In order to access the terms of the insurance contract or administer claims which arise, we will need to collect data which the Data Protection Act defines as sensitive such as medical history or criminal convictions. By proceeding with this contract you will signify your consent to such information being processed by the insurer or its agents.
YOUR RIGHTS On payment of a small fee you are entitled to receive a copy of the information we hold about you. If you have any questions, or you’d like to find out more about this notice you can write to the Data Protection Officer, Carrot Insurance, Global House, Westmere Drive, Crewe Business Park, Crewe, CW1 6ZD.
YOUR RESPONSIBILITY Although we may undertake searches and make enquiries to help us verify your information, it remains your responsibility to take reasonable care to ensure that all answers to questions, statements and other information you provide to us are accurate and complete.
Carrot Insurance is a trading style of Carrot Risk Technologies Limited. Carrot Risk Technologies are authorised and regulated by the Financial Conduct Authority (FCA) under firm reference number 610895. Carrot Risk Technologies Limited, company number 07771243 registered in England and Wales. Registered address: Global House, Westmere Drive, Crewe Business Park, Crewe, CW1 6ZD.
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