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Declaration Statement
The proposer is domiciled in Great Britain, Northern Ireland or the Isle of Man and is aged 18 years or older at the start date of this insurance.
Within the last 5 years, the proposer has not:
• Been declared bankrupt
• Entered into any arrangement with their creditors
• Had any County Court Judgments (CCJs) made against them
• Been a director of any company, or a member of a limited liability partnership (LLP), which went into administration, involuntary receivership, or insolvent liquidation.
Within the last 5 years the proposer has not had an insurance policy cancelled or voided by an insurer or been otherwise refused insurance.
The proposer does not have any unspent convictions according to the Rehabilitation of Offenders Act 1974, nor have any prosecutions pending. (Motoring offences that do not involve a custodial sentence do not need to be disclosed).
The proposer agrees to their data being stored by Peliwica Insurance in line with their Privacy Policy, which can be read in full on the Peliwica website.
I, the Broker, hereby confirm that all the information provided on behalf of the proposer is accurate, and I understand that if I do not provide accurate information on behalf of the proposer this may adversely impact the level of cover provided and any potential claims.