John Russell Insurance Services Ltd - John Russell Insurance Services Ltd

Wanderer & Gull Spirit Proposal Form

To arrange cover complete the form below, print and then sign it and post to:

John Russell Insurance Services Limited
536 Coventry Road
Small Heath
Birmingham
B10 0UN

You must give true and full answers to all the questions. If you do not do so, your insurance cover may not protect you in event of a claim. Axa General Insurance Limited is a member of the Axa Group. To set up and administer your policy we will hold and use information about you supplied by you. We may send it in confidence for processing to other companies in the Axa Group (or companies acting on our instructions) including those located outside the European Economic Area. By signing this form you consent to such use of your personal data. Axa Insurance UK plc may send you details of other products and services. To enable them to send you details of their services we may also share your name and address with other Axa Group companies based within the European Economic Area and with other carefully selected companies outside the Axa Group. You may be contacted by phone, fax or E-mail if appropriate. If you do not wish to receive such details please tick box.

You and we are free to choose the law applicable to this contract. In the absence of an agreement to the contrary the law of England and Wales will apply. If you reside in (or in the case of business, the registered office/principal place of business is in) Scotland, Northern Ireland, the Channel Islands or the Isle of Man the law applicable to that appropriate country will apply. Upon acceptance of the risk a copy of this proposal form will be returned with the policy document.

Full Name

Full Address
Post Code
Phone Number	E-mail
Occupation

Details of Vessel
Name		Class
Sail Number		Date Built
Length		Hull Material

Is the vessel left afloat unattended on moorings	Yes or No
Details of the engine

Outboard Yes or No	Manufacturer
Year of Manufacture	BHP
Speed	Serial Number

Give details of all accidents and losses that have occurred during the past 5 years inconnection with any vessel you have owned or used (if none state NONE)

Have you or any person having an interest in the vessel been convicted of or received apolice caution for or been charged with but not yet tried with any offence other thandriving offences: Yes or No

Is the vessel used for private pleasure purposes only: Yes or No

Values to be insured: The value to be insured should be: 1. In respect ofnew property - the purchase price. 2. In respect of other property the current market value of the particular item.

Dinghy + equipment £	Purchase Price £	Yr. Purchased
Outboard Motor £	Purchase Price £	Yr. Purchased
Road Trailer £	Purchase Price £	Yr. Purchased
Launching Trolley £	Purchase Price £	Yr. Purchased
Total Value £

State amount of NCB (no claim bonus) allowed at last renewal (if any) %

Date cover to commence (cover only effective when proposal received and accepted)

I/We declare that to the best of my/our knowledge and belief the particulars and answersare true. I/We consent to the seeking of information from other insurers to check theanswers I/We have provided, and I/We authorise the giving of such information for suchpurposes.

Date Signature ________________ (Signing doesn't bind Proposer or Company to complete cover)

I enclose a cheque for £ Payable to John Russell Insurance Ltd