| Vehicle Selection: |
| Manufacturer: |
|
Model |
|
| Style, eg; saloon, estate: |
|
Engine size: |
|
| Year of registration: |
|
Reg No. (If known) |
|
| Transmission: |
Manual
Automatic |
Value: |
|
Does the car have an insurance
approved alarm: |
Yes
No |
|
|
| Cover Selection: |
| Cover required: |
Fully comprehensive
Third Party Fire and Theft
Third Party |
|
| Years no claims bonus earned: |
|
No claims protected: |
Yes
No |
| |
|
Business Use required: |
Yes
No |
| |
|
Carriage of goods required: |
Yes
No |
| Overnight: |
| where will the car be kept over night: |
Garage
Private Drive
Public road |
|
| First Named Driver: |
| Surname: |
|
First Name: |
|
| Occupation: |
|
Date of birth: |
|
| Years residence in the UK: |
|
Marital status: |
|
| Tel Number: |
|
Mobile Number: |
|
Please indicate type of
licence and how long held: |
UK Provisional
UK Full Licence
Foreign Full Licence |
|
|
|
|
|
|
| Accidents, claims and convictions: |
| Have you had any claims within
the last 5 years: |
Yes
No |
|
|
If yes please provide details
including date, amount of claim
and if it was yours or a third
partys fault. |
|
| ------------------------------------------------------------------------------------------------------------------------------------------ |
Have you had any motoring
convictions within the last 5
years: |
Yes
No |
|
| If yes please provide details: |
Conviction code, ie SP30:
|
|
| |
Date of conviction:
|
|
| |
Number of points: |
|
| |
Amount of fine: |
|
| |
If banned, no's of months:
|
|
| ------------------------------------------------------------------------------------------------------------------------------------------ |
| |
Conviction code, ie sp30: |
|
| |
Date of conviction: |
|
| |
Number of points: |
|
| |
Amount of fine: |
|
| |
If banned, no's of months:
|
|
| Medical conditions / disabillities: |
| Do you have any medical disabilities notifiable to the DVLC |
Yes
No |
|
|
| If yes please give details: |
|
| Business Use: |
Other than commuting will you
or any other driver be using the
car for any business use: |
Yes
No |
|
|
| If yes please give details: |
|
| If cover is required for a single driver please submit the details now
|
|
|
| Second Named Driver: |
| Surname: |
|
First Name: |
|
| Occupation: |
|
Date of birth: |
|
| Marital Status: |
|
Years Resident in the UK: |
|
Please indicate type of
licence and how held: |
UK Provisional
UK Full Licence
Foreign Full Licence |
|
|
|
|
|
|
| Second Named Driver - Accidents, claims and convictions: |
| Have you had any claims within
the last 5 years: |
Yes
No |
|
|
If yes please provide details
including date, amount of claim
and if it was yours or a third
partys fault. |
|
| ------------------------------------------------------------------------------------------------------------------------------------------ |
Have you had any motoring
convictions within the last 5
years: |
Yes
No |
|
| If yes please provide details: |
Conviction code, ie SP30:
|
|
| |
Date of conviction:
|
|
| |
Number of points: |
|
| |
Amount of fine: |
|
| |
If banned, no's of months:
|
|
| ------------------------------------------------------------------------------------------------------------------------------------------ |
| |
Conviction code, ie sp30: |
|
| |
Date of conviction: |
|
| |
Number of points: |
|
| |
Amount of fine: |
|
| |
If banned, no's of months:
|
|
| Third Named Driver: |
| Surname: |
|
First Name: |
|
| Occupation: |
|
Date of birth: |
|
| Marital Status: |
|
Years Resident in the UK: |
|
Please indicate type of
licence and how long held: |
UK Provisional
UK Full Licence
Foreign Full Licence |
|
|
|
|
|
|
| Third Named Driver - Accidents, claims and convictions: |
| Have you had any claims within
the last 5 years: |
Yes
No |
|
|
If yes please provide details
including date, amount of claim
and if it was yours or a third
partys fault. |
|
| ------------------------------------------------------------------------------------------------------------------------------------------ |
Have you had any motoring
convictions within the last 5
years: |
Yes
No |
|
| If yes please provide details: |
Conviction code, ie SP30:
|
|
| |
Date of conviction:
|
|
| |
Number of points: |
|
| |
Amount of fine: |
|
| |
If banned, no's of months:
|
|
| ------------------------------------------------------------------------------------------------------------------------------------------ |
| |
Conviction code, ie SP30: |
|
| |
Date of conviction: |
|
| |
Number of points: |
|
| |
Amount of fine: |
|
| |
If banned, no's of months:
|
|
| Please note the above information will be used to obtain an indication of the premium required, it may be nessecary to obtain further details in order to confirm the premium and any conditions applying to the cover |
|
|
