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Statement of Fact for your Motor Vehicle Insurance.

Here is the information you have supplied.

This will be used to form the basis of your insurance contract and is called `The Statement of Fact'. The Statement of Fact is a record of the information about yourself and your insurance requirements advised to Abbeygate Insurance. These details have been taken into account when calculating the premium and terms on which your quotation is based. If there is any information omitted or incorrect, you have a duty to inform us immediately, failure to disclose to us such necessary information could invalidate your insurance or result in a claim not being paid. We will advise you of any revised premium and/or changes to terms and conditions that may result from additions or amendments you make and send you a new Statement of Fact.

You should check this form immediately and if any of the information is incorrect, please contact our Customer Care Team.

Information Held

For your protection, calls may be recorded and regularly monitored. The data controller in relation to any personal data you supply is held with Abbeygate. Information you supply may be used for the purpose of arranging insurance on your behalf and may be disclosed to insurance companies concerned. Abbeygate may use your information to keep you informed by post, telephone, email or other means about products and services that may be of interest to you. (Your information may also be disclosed and used for these purposes after your policy has lapsed). If you do not wish your information to be used for these marketing purposes, please write to Abbeygate, Apartardo 166, Guadiaro, 11311 Cadiz.

Insurers pass information to the claims and underwriting exchange register, run by Insurance Database Services (IDSL) 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. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim.

When you tell us about the incident, we will pass the information relating to it to the registers. Your insurance cover details will be added to the Motor Insurance Database, run by the Motor Insurers Information Centre (MIIC). This has been set up to help identify uninsured drivers and may be searched by the police to help confirm who is insured to drive. If there is an accident, the database may be used by insurers, MIIC and the Motor Insurers Bureau to identify relevant policy information. You can ask more about this. You should show this notice to anyone insured to drive the vehicle covered under the policy.

All the above information will also be retained and updated by your Insurers.

1. Your Details
Proposer’s Name
Address
Address
Date of Birth
Telephone Number
Email Address

3. Vehicle Details
Make	Model			Cabrio
CC	Year			Fuel Type
Reg. No			Country of Reg
Value €		Kms per year
In the car Left Hand Drive or Right Hand Drive?
How many seats does the vehicle have?
Has the car been fitted with any optional extras/modifications since manufacture? If yes enter details
Is the vehicle fitted with an alarm?
Is the vehicle fitted with an immobiliser?
Parking location
Is the vehicle fitted with an approved Tracker?					What Make
Has the vehicle been imported from outside the EU?
Use of Vehicle					SDP and Limited Business use by Proposer
When was the vehicle purchased and how much was paid?
Are you or your spouse the legal owners of the vehicle?

4. Cover Details
Cover
Do you want Motor Breakdown Cover?
How many years no claims discount are you claiming?
Name/Policy No. of Last Insurer
Will the vehicle be taken outside the Iberian peninsula for more than 90 days at a time or outside the EU at anytime?

5. Driver Details - Proposer
Name	AS ABOVE
Date of Birth	AS ABOVE
Gender
Is this the main driver of vehicle	YES
Nationality
NIF/NIE/Passport Number
Licence type (Full, Provisional)
Country of Issue of Licence
Date of issue of driving Licence (dd/mm/yyyy)
Occupation
Nature of Business
If you are over 70 years of age, have you had a recent medical and been passed fit to drive?


5(a). Driver Details – Additional Driver 1
Name
Date of Birth
Gender
Is this the main driver of vehicle	NO
Nationality
NIF/NIE/Passport Number
Licence type (Full, Provisional)
Country of Issue of Licence
Date of issue of driving Licence
Occupation
Nature of Business
If you are over 70 years of age, have you had a recent medical and been passed fit to drive?

5(b). Driver Details - Additional Driver 2
Name
Date of Birth
Gender
Is this the main driver of vehicle	NO
Nationality
NIF/NIE/Passport Number
Licence type (Full, Provisional)
Country of Issue of Licence
Date of issue of driving Licence
Occupation
Nature of Business
If you are over 70 years of age, have you had a recent medical and been passed fit to drive?

5(c). Driver Details – Additional Driver 3
Name
Date of Birth
Gender
Is this the main driver of vehicle	NO
Nationality
NIF/NIE/Passport Number
Licence type (Full, Provisional)
Country of Issue of Licence
Date of issue of driving Licence
Occupation
Nature of Business
If you are over 70 years of age, have you had a recent medical and been passed fit to drive?

Important: In the case of a claim where the driver of the vehicle is less than 30 years old and is not named in the proposal form and/or policy the Own Damage cover will be excluded from the Comprehensive policies (Importante: en caso de siniestro, si el conductor del vehiculo fuera menor de 30 anos de edad y no ha sido designado en la solicitud de seguro o/y en la poliza la cobertura de danos Propios de las polizas suscritas en la modalidad todo riesgo quedara excluida)

6. Accident Details
Name	Date	Details	At Fault	Third Party Costs	Own Costs	Claim Status (Active, Settled)	Own Costs recovered?

7. Conviction Details (Including fixed penalty notices)
Name	Offence Date	Conviction Date	Code	Points	Licence Endorsed	Sample level	Section Ban	Accident Occur

1. Law applicable to contract

You and the insurer are free to choose the law applicable to this contract but in the absence of agreement to the contrary, the law of the country in which you reside at the date of the contract(or in the case of a business , the law of the country in which the registered office or principal place of business is situated) will apply.

2. Motor Insurance Database

If the vehicle you are insuring is registered in the United Kingdom 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.

3. Trailers

The cover in respect of Trailers is for Third Party Legal Liabilities only. There is no cover for loss or damage to the trailer or goods being carried, nor whilst the trailer is detached from the vehicle insured.

4. Territorial limits

This Certificate of Motor Insurance takes the place of an International Motor Insurance Green Card and is evidence that the insurance extends to include the compulsory motor insurance requirements of:

(El certificado de seguro de automoviles que le fue presentado reemplaza a la tarjeta international de seguros de automoviles (‘la Tarjeta Verde’) y demuestra que el seguro se extiende para incluir los requisitos obligatorios de seguros de automoviles de:)

Any member of the European Union (cualquier pais mienbro de la Union Europea)

The Isle of Man and the Channel Islands

Norway and Switzerland (Noruega y Suiza)

5. Declaration

To the best of my knowledge and belief the information provided on this proposal, whether in my own hand or not, is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact may entitle Underwriters to void the insurance.

N.B. A material fact is one likely to influence acceptance or assessment of this proposal form by Underwriters. If you are in any doubt as to whether a fact is material or not you must disclose it in the space below.

I/We hereby declare that neither I/W