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g.     Date of commence of cover:

 

h.     Do you wish to pay by monthly payment plan (UK residents only):                            Yes/No

i.      Additional information (please continue on separate sheet if necessary):

 

 

5. DECLARATION AND IMPORTANT INFORMATION

Important Information:
Sometimes in order to assist you a large proportion of the statement of fact or proposal form may have been completed on your behalf.  It is therefore essential that you check the answers given and amend any that are incorrect or complete any that are not completed.  It is your responsibility for any non-disclosure or misrepresentation of any material fact and your attention is drawn to the declaration below.

Declaration:
I/We declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any material facts. (A material fact is one likely to influence the underwriter’s assessment of this proposal). I/We agree that this proposal, together with any other information supplied by myself/ourselves shall form the basis of any contract of insurance affected thereupon. I/We undertake to inform Matrix Insurance Services Ltd of any material alteration to these facts occurring before completion of the contract of insurance.

Name:

Position:

Signature: 

Date:

 

We are committed to ensuring that our customer’s personal information is protected. We treat all personal information in compliance with the Data Protection Act 1998. We may for the purpose of facilitating the arrangement of insurances and related services and products forward your information to third parties.

DOCUMENTS YOU MUST SUPPLY:
Quotations can only be provided if you supply a copy of your standard terms and conditions of business.

Document

Attached Yes/No (please circle)

1. C.Vs of Key Staff members

Yes/No

2. Terms of Business

Yes/No

3. Claims Details

Yes/No


Quotation  Deadline Date:

Broker Ref Only:


Please send your completed proposal form with your documents to:

Matrix Insurance Services, Matrix House, Orchard Business Park, Furnace Lane, Horsmonden, Kent. TN12 8LX
Fax: 01892 724058
Email: enquiries@matrix-ins.co.uk
Tel: 01892 724060
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