Motor Insurance Application

Complete all sections below. Fields marked with * are required. You can also download the PDF version

Part 1: You / The Insured

Full Name (Mr/Mrs/Ms/Company) *

Address (where vehicle is located when not in use)

Gated?

Garaged?

Date of Birth

Home Phone

Work Phone

Cell Phone *

P.O. Box

Email Address *

Employer

Occupation

Usual Working Hours

How long have you been driving? (years)

How long held license in The Bahamas? (years)

Type of License Held

License No.

Expiry Date

Do you have any other insurance coverage with NAGICO?

YesNo

Have you ever or do you now hold a Motor Insurance Policy?

YesNo

Are you entitled to a No Claims Discount?

YesNo

Part 2: The Vehicle

Make *

Model *

Year *

Seating

Registration No.

Engine Capacity

Chassis/VIN

Purchase Date

Purchase Price

Where Purchased?

Estimated Value

If you are NOT the Registered Owner, please state Registered Owner:

Does a financial institution or individual have a financial interest in your vehicle?

YesNo

Have you made any conversions/modifications to the vehicle?

YesNo

Part 3: Use of Vehicle

Vehicle Usage

Will the vehicle be frequently driven between midnight (12 pm) and 6 am?

YesNo

Is it intended to use the vehicle for carriage of Goods/Services or towing of any trailer(s)?

YesNo

If used as a Public Service Vehicle, who is the Franchise Owner?

Does the vehicle carry any flammable, toxic, corrosive, explosive or otherwise dangerous substances?

YesNo

Part 5: Regular / Additional Drivers

Driver Coverage Option

Have you or your spouse had any motor insurance declined or cancelled for any reason?

YesNo

Had your/their license suspended or withdrawn?

YesNo

Suffer from any physical or mental disability, infirmity, disease?

YesNo

Been convicted of or received notice of intended prosecution for any motor vehicle offense?

YesNo

Part 6: Claims History

Have you or your spouse had any motor accidents/claims/losses during the past three (3) years?

YesNo

Required Documents

Driver's License * (Required)

Upload file

PDF, JPG, or PNG (Max 10MB)

Bill of Sale / Invoice / Certificate of Title * (Required)

Upload file

PDF, JPG, or PNG (Max 10MB)

Additional Documents (Optional)

Additional Driver's Licenses, Customs Documents, Franchise Letter, etc.

Upload files

You can upload multiple files

Declaration & Signature

I/WE wish to effect an insurance with NAGICO Insurance (Bahamas) Limited. I/WE declare that the above statements are complete and correct and that no material fact has been mis-represented, mis-stated or withheld. I/WE agree that this proposal shall form the basis of the contract between me/us and NAGICO Insurance (Bahamas) Limited and I/WE agree to accept NAGICO Insurance (Bahamas) Limited's usual form of policy for insurances of this nature.

If this proposal has been written by anyone else that person is my agent for that purpose and not the agent of NAGICO Insurance (Bahamas) Limited. I/WE agree that the insurance cover will not be in force until the application has been accepted by NAGICO Insurance (Bahamas) Limited.

Signature *

Sign above using your mouse or touch screen

Signing this application does not bind the Applicant or the Company to complete the insurance.

Download PDF Form Instead

Questions? Call (242) 448-2680 or email sherman@titaninsurancebahamas.com

Motor Insurance Application

Part 1: You / The Insured

Part 2: The Vehicle

Part 3: Use of Vehicle

Part 4: The Cover

Part 5: Regular / Additional Drivers

Part 6: Claims History

Required Documents

Declaration & Signature