Insurance Compliance Form (Sagicor) (BimCars) Step 1 of 5 20% HiddenCar Hire Operator*H2HomesUSave Car RentalsDey's Car Rental And TaxiDougie Roller Car RentalsG Squared Car RentalsScotty's Cheap Car RentalsRoadmap Car RentalsFirstClass Car RentalsName of Hirer* First Last Email* Phone*This can be your mobile number with Whatsapp,Your home number or a local number of where you are staying in BarbadosDate of Birth* DD slash MM slash YYYY Please use calendar icon to choose dateOccupation of Hirer* Who are you?* I am the main hirer I am an additional driver Driving License issue date* DD slash MM slash YYYY Please use calendar icon to choose dateDriving License Expire Date* DD slash MM slash YYYY Please use calendar icon to choose date If your license does not have an expiry date listed please choose any date a year in the futureDriving License Number* State number of years a full driving license has been held* Address of Hirer in Barbados* Street Address City Home Address of Hirer* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands *hint if you don't have a city or state you can put your province.If you don't know your postal code you can enter "00000" Give details of any physical infirmity,defective vision or hearing or of any mental or nervous illness*Give details of all driving convictions incurred during the immediate past 5 years including any that may be pending*Has any Motor Insurer ever done any of the following(If so give details)Declined your proposal?* Yes No Stipulated Special Conditions?* Yes No Required an increase in premium?* Yes No Required you to bear the first part of any loss?* Yes No Refused to renew your policy?* Yes No Cancelled your policy?* Yes No Please put the date and the descriptions for the items selected I understand that during the period of hire, the car may not be driven by any one other than myself. I also understand that this Insurance is governed by the Laws of Barbados whose courts shall have exclusive jurisdiction in the settlement of any claim, dispute or question arising in connection with this Insurance and in the event of any action, claim or demand by any Third Party. The liability of the insurers to indemnify shall be limited to judgements delivered or obtained in the first instance by a court of competent jurisdiction within Barbados. I warrant the statements made in the Proposal for Motor Insurance are true and shall be held to be promissory and shall form the basis of the contract between me and the Underwriters.Owner agrees to rent and the Hirer agrees to take the Vehicle described overleaf, subject to the terms and conditions of this Agreement. TERMS AND CONDITIONS. “The Hirer” means a person, by or on behalf of whom this Agreement is signed. “Authorised Driver” means the drivers additional to the Hirer who have completed a separate insurance proposal as overleaf, to the satisfaction of Sagicor General Insurance Inc. If the Hirer is a company, “Authorised Driver” will mean any employee of the company, who holds a valid driving permit, is over 21 years of age, has had no motor vehicle accidents during the past three years and is driving on the Hirer’s order or with his permission. The Hirer will ensure that any Authorised Driver will comply with all the terms and conditions of this Agreement. The Hirer will return the Vehicle with all tyres, tools and accessories, in the same condition as when received, ordinary wear and tear expected, to the place and on the date shown overleaf or sooner if requested by Owner. The Hirer will pay Owner on demand all charges due under this Agreement. If the Hirer has complied with all terms and conditions of this Agreement, responsibility for loss of or damage to the Vehicle or its tyres, tools or accessories is: (a) limited to a maximum of $1,500.00. (b) in the case of the Hirer being under the age of 25 or having been the holder of a full driving license for less than 2 years $3,000.00. The Hirer will at the request and cost of Owner do all required by Owner and permit his name to be used by the Owner for enforcing any rights or remedies against other parties in connection with the Vehicle during the period of Rental. Owner will give credit to the Hirer for any monies recovered from other parties against any liability of the Hirer to Owner for the loss or damage. The Hirer or any Authorised Driver of the Vehicle will in no event be deemed the agent, servant or employee of Owner. Owner will in no event, be liable for any loss of or damage to any property left or placed by the Hirer or any other person in or on the Vehicle or the premises of Owner either before, during or after the period of Rental. The Hirer will indemnify Owner against all claims for any such loss or damage. (a) The Vehicle is covered against third party (including passengers) liabilities by a third party insurance policy, a copy of which may be inspected during normal business hours at the Office of Owner. The policy provides an Indemnity for third party bodily injury or death and damage to third party property. The Hirer for himself and on behalf of any Authorised Driver agrees to comply with and be bound by all the terms of this policy, which are hereby incorporated by reference into this Agreement. It is a requirement of the policy that every accident involving the vehicle will be reported at once to the Owner and an accident report form completed within 24 hours. The Hirer or any Authorised Driver will: obtain the names and addresses of witnesses, if possible; make no admission of liability; deliver to the Owner all summonses, writs and documents received; not aid or abet any claimant but co-operate fully with Owner and the Insurance Company in the investigation and defence of any claim. (b) The Vehicle will not be used: for the carriage of passengers or property for Hirer or reward; for any illegal purpose; to propel or tow any other vehicle or trailer; for racing, pacemaking, reliability trials, speed testing, or driving tuition; violation of the provision of any Act, Order or Regulation affecting the use, loading or condition of the Vehicle.; (c) The Vehicle will not be driven by any person; I. other than the Hirer or any Authorised Driver; II. who has given a fictitious or false name, age or address; III. who is under the influence of alcohol, hallucinatory drugs, narcotics, or barbiturates The Hirer will immediately inform Owner of any loss, of damage to or fault in Vehicle and will not use the Vehicle while it is in an un-roadworthy condition or liable to cause damage to any person or property. Owner accepts no responsibility for delays in consequence of breakdown or other circumstances. All traffic offences or violations of parking regulations involving the vehicle during the period of rental, including all fines or penalties will be the responsibility of the Hirer. No right of Owner under this Agreement will be waived except in writing signed by a duly Authorised Representative of Owner IMPORTANT NOTICE YOU HAVE JUST HIRED A MOTOR VEHICLE FROM US FOR YOUR USE WHILE IN BARBADOS. WHILE WISHING YOU HAPPY DRIVING, WE WOULD LIKE TO TAKE THE OPPORTUNITY TO DRAW YOUR ATTENTION TO THE FOLLOWING POINTS:- THE INSURANCE PROTECTION ON THIS VEHICLE IS VALID ONLY WHEN IT IS BEING DRIVEN BY THE “AUTHORISED” PERSONS. ALLOWING ANY OTHER PERSON TO DRIVE THE MOTOR VEHICLE CAUSES THE VEHICLE TO BE ON THE ROAD WITHOUT OPERATIVE INSURANCE, AND SHOULD THIS HAPPEN WHILE THE MOTOR VEHICLE IS UNDER HIRE TO YOU. YOU WOULD BE COMMITTING A BREACH OF THE LAW AND WOULD BE LIABLE TO PENALTIES UNDER THE LAW. FURTHER, IN THE EVENT OF AN UNFORTUNATE ACCIDENT WHILE THE VEHICLE IS BEING DRIVEN BY AN UNAUTHORISED PERSON, YOU WOULD BECOME PERSONALLY LIABLE FOR ANY CLAIMS FOR DAMAGE TO THE VEHICLE OR COMPENSATION TO THIRD PARTIES. WE ARE SURE YOU WOULD LIKE TO AVOID GETTING INVOLVED IN SUCH SITUATIONS AND HENCE THIS SPECIAL APPEAL POINTING OUT THE RESTRICTIONS OF THE PROTECTION.Consent* I have read the all of the terms and conditions of the rental and agree to it Invoice Id Delivery details*Enter details required for delivery of the vehicle. This would be the address and a telephone number for the Guest house or hotel you are staying. If collecting at the Airport this would be your flight number.Start Date of Rental* DD dash MM dash YYYY The day you are collecting the vehicle Please use calendar icon to choose dateTime of delivery* Hours : Minutes AM PM AM/PM The time you would like the vehicle delivered forEnd Date of Rental* DD dash MM dash YYYY The date you are returning the vehicle Please use calendar icon to choose dateReturn Time* Hours : Minutes AM PM AM/PM Time you are returning the vehicleReturn Location detailsLeave blank if the same as delivery informationDriver's License Front Picture* Use your phone and upload a picture of the front of your driver's licenseDriver's License Back Picture* Use your phone and upload a picture of the back side of your driver's licenseDeposit to be held?On Credit CardIn CashDeposit Held by Main HirerSecurity Deposit-The vehicle comes with fully comprehensive insurance. If the Hirer has complied with all terms and conditions of this Agreement, the hired car operator agrees to limit responsibility for damages to the Vehicle or its tyres, tools or accessories: up to the insurance deductible listed above. This limitation of liability does not apply to liability not covered by the cars insurance coverage.By completing this form, you authorize the car hire operator to charge you, either by credit card or otherwise for any damages and fees not covered by the insurance after the vehicle is returned. You fully authorize the car hire operator directly or through their agents or third party acting on their behalf to take payments from you either via credit card or otherwise for any damages, penalties and or fees related to your rental of the vehicle.The value of damages will be assessed solely by the hired car operator up to the amount of the deductible or more for damages or claims not covered by insurance. You agree that any charges made in this respect are not in dispute and are authorized . An invoice will be forwarded to you for any charges made directly for fee, penalties or damages. Price: Credit Card American ExpressDiscoverMasterCardVisaJCBMaestroSupported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro Card Number Expiration Date Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name Please enter the details for the credit card you are authorizing us to charge to cover cost of any damages that may occur. Your card information will be stored securely with "Stripe" payment priocessorHiddenDamages FormHiddenSignature of Hirer____________________________________________________________ Hired Car Registration Number: Date: