Haven Taxi Web

Statement of Fact - Motor Insurance

Acorn Direct Web Policy Number/Client Ref HAVTX-531222/0

Acorn Insurance & Financial Services Ltd 98, Liverpool Road Broker Reference HUSS/T/452349MOZU
Formby Scheme: Haven Taxi Web
Liverpool Agency Number (If known)
L37 6BS

IMPORTANT - PLEASE READ CAREFULLY

These are the details supplied by you on which the underwriting of your insurance policy is based. If you are satisfied that, to the best of your knowledge
and belief, this is a true statement of the facts you need take no further action. If any of the following details appear to be incomplete or incorrect please
contact your broker immediately to notify them of any errors. If the Risk remains acceptable you will be advised of any changes in the premium or terms.
Failure to do so could lead to your policy being cancelled or declared void and any subsequent claims could be refused.

Your Details Please initial any alterations

Full Name Mr Talib Hussain Marital Status Married Contact Numbers

Full Address 196 Abbey Hills Road Gender Mobile 07710245158

OLDHAM E-Mail Address [email protected]
OL8 2DQ Residential UK resident
Status
Have you had a County Court Judgement registered against you in the past six years and/or defaulted on any credit agreement? No
Occupation Taxi Driver Home Owner Homeowner

Cover
Cover to commence at 00:00:00 on 14/11/2023 For a period of 1 Year
Type of cover Comprehensive Voluntary excess 250

Driving restriction Insured Only No Claims Bonus Protection required (if available) No

Vehicle Details
Make and Precise Cubic
Model TOYOTA COROLLA HYBRID EXCEL VVT-I Capacity 1987 Body Type Estate Car/Station Wagon
Year of first
Registration number ML19WPY registration 2019 Is the vehicle Q Plated? No Number of Seats
Estimated annual Has the vehicle been
Purchase price 0 mileage 3000 imported? No 5

Purchase date 01/05/2019 Current mileage 0 Vehicle owned by Proposer/Policyholder

Business mileage 16000
Estimated Value 20310 ABI code 50077804 Registered keeper Proposer/Policyholder
Are there any security devices fitted and in operation on this vehicle? If ‘Yes’ provide details below Yes
Has your vehicle been modified, altered or adapted in any way from the manufacturer’s standard specification , including any manufacturer or dealer fitted options, whether or not
performance is altered, or do you intend to alter it later? If ‘Yes’ provide details below No

Details of any security or tracking devices fitted to the vehicle Details of any Modifications to the Vehicle
Cert Modification
Security Device Installer Seen Ind Modification Type Value (£)
Vehicle Manufacturer No 0
Unspecified Cat 1
No 0

NB Failure to disclose any modification could result in the policy being declared invalid. If in doubt you should disclose it.
E.g. engine or body modifications, special or non-standard equipment, non-standard or alloy wheels, cosmetic changes, sound systems

State the address at which 196

the vehicle is normally kept Abbey Hills Road
Overnight Left/Right
Location Garage Hand Drive Right
OLDHAM
OL8 2DQ

Policy Number: HAVTX-531222/0 Printed on: 07 November 2023 Page 1 of 3 200709/01

 Give Details Below of All Persons Who Will Drive the Vehicle, Including Yourself (Drivers under 25 years of age must be disclosed)

Full Name Mr Talib Hussain

Marital Status & Gender Married

Date of Birth & Age 11/06/1971 age: 52

UK Residency (years) 52

Type of driving license held Full UK Car Licence

Period driving license held (years) 35

Date driving test passed 01/07/1988

Occupation (1st occupation) Taxi Driver

Nature of employers’ business Taxi Service

(1st occupation)

Employment Status (1st occupation) Self Employed

Occupation (2nd occupation if

applicable)

Employers’ business (2nd occupation if

applicable)

Employment Status (2nd occupation if

applicable)

Relationship of this driver to the Proposer

Proposer

Are you the Main User of this vehicle? Yes

Nature of this driver’s use of this Private Hire

vehicle?

Does this driver own another vehicle? No

Does this driver have use of another

vehicle? No

Have you been convicted of any

non-motoring offence, including No
offences relating to theft, fraud or
dishonesty? *

Have you any prosecution or police No

enquiry pending? *

Have you been disqualified from No

driving? *
Have you been declined or refused
any type of insurance or had any No
special term imposed? *

Have you had previous terms No

applied? *

Restrictions to licence No Restrictions

THE ONUS IS ON YOU TO ENSURE THAT YOU AND ALL NAMED DRIVERS HOLD A VALID DRIVING LICENCE(S)
AND/OR CBT CERTIFICATE (IF APPLICABLE) FOR THE VEHICLE(S) YOU ARE PROPOSING TO INSURE.
FAILURE TO HOLD A VALID LICENCE WILL MAKE THIS INSURANCE INVALID AND ALL COVER WILL STOP
FROM THE START OF THE CONTRACT.
WE RESERVE THE RIGHT TO REQUEST A COPY OF ANY DRIVER’S LICENCE AT ANY TIME.

Insurance History
Name of previous insurer Policy number
Number of years No Claims Bonus 3 Expiry Date 30/12/1899
Type of policy Private Hire

Driving History

Claims
Have you or any person who may drive been involved in any accident, claim or loss (including loss by fire, theft or malicious acts), irrespective of blame,
during the past three years? Yes If ‘Yes’ please provide full details below .
Driver Name Date Claim Type Claim Status NCD At Costs (£)
Affected? fault?

Talib Hussain 23/06/2022 Accident Settled No No 2843

Convictions
Have you or any person who may drive been convicted of any motoring offences , including fixed penalty offences, within the last five years?
If ‘Yes’ please provide full details below .
Alcohol Reading Disqualification Period
Driver Name Date Motoring Offence Code (if any) Fine (£) Penalty Points (Months)

Policy Number: HAVTX-531222/0 Printed on: 07 November 2023 Page 2 of 3 200709/01

 Medical

Does any driver suffer from a notifiable medical condition not notified to DVLA or any condition for which DVLA have restricted the licence ? No
If ‘Yes’ please provide full details below .
Driver Name Nature of Condition Date of onset DVLA Advised?

Mr Talib Hussain

Qualifications

Has any driver passed a Motoring Qualification? No If ‘Yes’ please provide full details below .
Driver Name Qualification Description Date Obtained

Mr Talib Hussain Private Hire 01/09/2014

If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies. Law enforcement agencies may access and use this information.
We and other organisations may also access and use this information to prevent fraud and money laundering , for example, when: Checking details on applications for credit and credit
related or other facilities, Managing credit and credit related accounts or facilities, Recovering debt, Checking details on proposals and claims for all types of insurance, Checking details
of job applicants and employees. Please contact us at 01704 270027 if you want to receive details of the relevant fraud prevention agencies. We and other organisations may access and
use from other countries the information recorded by fraud prevention agencies.

Policy Number: HAVTX-531222/0 Printed on: 07 November 2023 Page 3 of 3 200709/01