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If I can be of any further assistance please do not hesitate to contact me.

These notes/documents were created or received by a person in the course of trade, business,
profession or other occupation, or as the holder of a paid or unpaid office and the information contained in
the notes/documents was supplied by a person (whether or not the maker of the statement) who had, or
may reasonably be supposed to have had, personal knowledge of the matters dealt with and where the
information contained in the notes/documents was supplied directly or indirectly each person through
whom it was supplied received it in the course of a trade, business, profession or other occupation, or as
the holder of a paid or unpaid office and the person who made the statement cannot reasonably be
expected (having regard to the time which has elapsed since he made the statement and to all the
circumstances) to have any recollection of the matters dealt with in the statement.

Signature: ………………….. Signature witnessed by:……………………………

KGM Motor Insurance T +44 (0)20 8530 7351 Registered in England and Wales No 01514453
KGM House F +44 (0)20 8530 8547 Registered Office Gallery 9 One Lime Street London EC3M 7HA
14 Eastwood Close T +44 (0)844 412 6412 Claims KGM Motor Insurance is a brand name for business written by
South Woodford F +44 (0)20 8530 7037 Claims Syndicate 260 which is managed by Canopius Managing Agents Limited
London E18 1RZ www.kgminsurance.co.uk Authorised by the Prudential Regulation Authority and regulated by the
UK www.canopius.com Financial Conduct Authority and the Prudential Regulation Authority

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