MGA Contractors & Trades – Commercial Motor Insurance Declaration

Items marked with * are required. You MUST fill them in before you can submit.

About You
Your Contact Name:
Your Contact Phone Number:
Your Contact Email Address:
Please confirm your Occupation:

Please confirm your Occupation: Electrician HVAC Contractor Painter & Decorator Plumber Other
Other Occupation
Please confirm your business name
Please confirm your business address
About Your Vehicles
How many vehicles would you like to quote
Registration Number of Vehicle 1
Registration Number of Vehicle 2
Registration Number of Vehicle 3
Registration Number of Vehicle 4
Registration Number of Vehicle 5
Registration Number of Vehicle 6
Registration Number of Vehicle 7
Registration Number of Vehicle 8
Registration Number of Vehicle 9
Registration Number of Vehicle 10
A broker will be in contact with you to request a copy of your schedule of vehicles.
Claims & Driver History
In the past 5 years, have you made a claim for Motor Insurance on any of the vehicles listed above?

In the past 5 years, have you made a claim for Motor Insurance on any of the vehicles listed above? Yes No
Please advise the vehicle registration, year of claim, type of damage and amount claimed below.
In the past 5 years, have you or any usual driver of your vehicles had their licence suspended, cancelled, or been convicted of any driving offence (excluding parking fines & tickets)?

In the past 5 years, have you or any usual driver of your vehicles had their licence suspended, cancelled, or been convicted of any driving offence (excluding parking fines & tickets)? Yes No
Please advise the year and details of the offence below
Do you ensure all your drivers are have a valid & current licence to drive the insured vehicles?

Do you ensure all your drivers are have a valid & current licence to drive the insured vehicles? Yes No
Duty of Disclosure & Declaration
You have a Duty of Disclosure to advise the insurer of any information that is relevant to the underwriting assessment of your business. Is there any information that you need to disclose to the insurer that would be relevant in assessing the risk associated with insuring your business for Commercial Motor Insurance?

You have a Duty of Disclosure to advise the insurer of any information that is relevant to the underwriting assessment of your business. Is there any information that you need to disclose to the insurer that would be relevant in assessing the risk associated with insuring your business for Commercial Motor Insurance? Yes No
Please advise below
My declaration

My declaration I declare that all of my answers above are true and accurate

MGA Contractors & Trades – Commercial Motor Insurance Declaration

MGA Contractors & Trades – Commercial Motor Insurance Declaration

About You

About Your Vehicles

A broker will be in contact with you to request a copy of your schedule of vehicles.

Claims & Driver History

Duty of Disclosure & Declaration