Scania Heavy Motor Insurance Risk Information Request Applicant* Business Description* Vehicle Details NOTE Truck VIN numbers will be required for Scania Finance as needed Year* Make & Model* REGN* Sum Insured* Total Value* Areas of Operation* Transport Runs Shorthaul - Metro* Please Select None 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Shorthaul - Regional* Please Select None 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Longhaul (+200kms point to point)* Please Select None 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Run Details* Number of Shifts* Main Base Location* Is this also the location where the truck(s) are stored when not in use? * Please Select Yes No If No, please advise details below Freight Items Carried* Type of Carriage* Please Select Limited Carriers Risk Owners Risk Declared Value Declared Terms Driver Details Number Of Drivers* Please Select 1 2 3 4 5 6 7 8 9 10 or more... Main Drivers* Driver Name* Number of years driving *Any losses or conviction * Yes or No Driver Name* Number of years driving *Any losses or conviction * Yes or No Driver Name* Number of years driving *Any losses or conviction * Yes or No Losses/Claims Are You Currently Insured* YesNo Current Insurer & Renewal Date* Please note that this is the insurance company not the broker Have you or any intended driver been convicted of a motoring offence other than parking?* YesNo Have you or any intended driver had any motor accidents in the last 3 years?* YesNo Have you or any intended driver been charged with a log book offence?* YesNo Have you or any intended driver been charged with a log book offence?* YesNo Have you or any intended driver had your licence endorsed, cancelled or suspended?* YesNo Have you or any intended driver had any insurance declined, cancelled or special terms imposed?* YesNo Have you or any intended driver been charged with a criminal offence?* YesNo If you have answered Yes to any of the above please provide full details below To whom it may concern Name* First NameLast Name On behalf of* Address* Street Address 1 Street Address 2 Town/CityRegion Postal Code Date* -Day -MonthYearDate Submit Form Should be Empty:
