GasanMamo Insurance - Motor Proposal

Personal Motor Insurance Proposal Form

Personal Information

Title	Name *	Surname *	ID Card Number *	E-Mail Address *

Residence Address *	Town *

Relevant Information

Gender *	Date of Birth (dd/mm/yy) *	Age *	Marital Status *

Principal Occupation *	Employer's Business *	Employment Status *

Secondary Occupation (optional)	Employer's Business (optional)	Employment Status (optional)

Vehicle Information

Do You OWN the Vehicle?	If not please explain:	Registration Number
Yes No

Engine Number	Chassis Number	Vehicle Make (eg. Honda, Fiat etc.)	Vehicle Model (eg. Civic, Bravo etc.)

Year of Manufacture	Colour	Engine/Cubic Capacity (cc)	Fuel Type	Seating Capacity(including driver	Drive Type

Modifications (eg body kit & engine)	If Modified please Explain:	Is an Alarm Installed?	If yes state the Name

Body Type	Estimated Value:	Where Is It Kept Overnight?	Main Purpose Of Use (social, commuting, business):

Type Of Cover:	Have you been previously insured?	If yes state the name of the insurer	Are you entitled to No Claims Discount?	If yes how many years?

Registration Numbers of other cars insured with us	Own Damage Excess (in addition to policy excess):

Driver Option:
	Policy Holder Only Policy Holders Plus one Additional Drivers Any driver aged 25 years or over Any driver aged 21 years or over Any driver aged 18 years or over

Driver Option:
	Caravan or Trailer Extension	Yes No
	Radio/Cassette Extension	Yes No
	Increased "Own Damage" Excess	Yes No
	Motor Plus Cover	Yes No

Please specify if you want to receive updates on promotions, or any third party offers

Yes No

IMPORTANT

You may forward this Proposal Form to us by clicking on "Submit Form". Please remember that cover will only commence once we have confirmed it to you in writing. You will also need to sign a printed version of your proposal form which will be sent to you together with the Certificate of Motor Insurance and Policy documents.

Data Protection Notice

To the extent that the information supplied by you, whether orally or in writing, constitutes personal data, including sensitive data within the provisions of the Data Protection Act, you consent to the processing of such data for purposes of administering your proposal for insurance, your Policy, underwriting, handling of claims and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. We maybe required to collect further information from our sub-agents, other insurance companies, insurance intermediaries or insurance associations.

In addition, we may pass some or all of the information to other insurance companies, or insurance associations for underwriting and claims handling purposes and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. This also helps us to check the information provided. When we deal with your request for insurance, we may search this information. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the Malta Insurance Association.

We and other companies within our group would like, on occasion, to keep you informed of our products and services, by mail, fax, e-mail or other electronic means. Please inform us in writing if you do not wish to receive this information or if you wish to receive such information solely from GasanMamo Insurance Ltd. Moreover, were hereby ask you whether you wish to receive direct marketing information from us by e-mail to your e-mail address provided below.

You have the right to request access to, and rectification of, your personal data held by us by directing your request in writing signed by yourself to the Data Protection Officer, GasanMamo Insurance Ltd, Msida Road, Gzira GZR 1405.

GasanMamo Insurance Limited is authorised to carry on business of insurance in Malta in terms of the Insurance Business Act 1998, regulated by the Malta Financial Services Authority. Company Registration Number: C3143