PRIVATE AND CONFIDENTIAL

Proposal For Motor Vehicles

Not linked to an estimate

Comprehensive and Third Party Coverage

Header meta

Branch/AgencyPeriod of Insurance fromPeriod of Insurance toSignature/Initial per pageDate per page

Premium Calculation

Underwriting-facing values are populated from the rating engine when available and remain editable by staff in the future operations app.

Gross PremiumNetTaxPremiumRATotal PremiumCopy received byDate

1. Proposer

(a) Name in full(b) Residential Address(c) Mailing AddressHomeWorkMobileEmail(e) Occupation/Profession(f) Employer's Name(g) Date of Birth

Sex

MaleFemaleOther

Marital Status

2. Other insurance with this Company?

Do you have any other insurance with this Company?

YesNo

If so, state

Privacy and consent notice

PICL collects the information in this motor proposal, including contact details and any uploaded documents, to assess insurance, claims, KYC, compliance, fraud prevention, customer support, and required record keeping.

Documents are stored in private systems and are shared only with authorized PICL staff, service providers, regulators, or legal authorities where needed. Retention periods and legal wording are placeholders for PICL legal review.

For privacy questions or complaints, contact PICL compliance. You may also contact the Trinidad and Tobago Information Commissioner where applicable.

I consent to PICL collecting, using, storing, and sharing this information for the purposes above. Version legal-placeholder-2026-07-02.