The proposer is domiciled in Great Britain, Northern Ireland, the Isle of Man, Jersey or Guernsey 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.
• It is understood that there is no cover for assistance if the vehicle is being used for motor racing, rallies, rental, hire, public hire, private hire, self-drive hire, courier services or any contest or speed trial.
• It is understood that there is no cover for any breakdown occurring within 24 hours of the policy starting or the policy being amended (i.e. a change of vehicle). This does not apply when renewing a policy (either renewing with Peliwica or switching from another provider at renewal).

I, hereby confirm that all the information provided is accurate, and I understand that if I do not provide accurate information, this may adversely impact the level of cover provided and any potential claims.