| Your Contact Details |
|
| Salutation |
|
| First Name |
|
| Last Name |
|
| Telephone Number |
|
| Email Address |
|
| Postcode |
|
|
| |
|
| Vehicle Details |
|
| Manufacturer (e.g. Lotus) |
|
| Vehicle Model (e.g. Elise) |
|
| Vehicle Varient (e.g. 111s) |
|
| Engine Size |
|
| Year of Manufacture (e.g. 2005) |
|
| Value of Vehicle |
|
| Are there any Modifications? |
|
| If Yes to the above, please enter the details here, including who carried out the modifications. |
|
| Will there be any Security Devices Fitted? |
|
| If Yes to the above, please enter security details here, including Thatcham catergory if applicable. |
|
| Who owns the vehicle |
|
| How long have you had this car for? |
|
| Are you a member of any Car Clubs? (This may entitle to you to a discount!) |
|
| If Yes to the above, give details of Car Club(s) |
|
|
| Main Driver Details |
| Who will be the Main Driver? |
|
| What is his/her date of birth? (dd/mm/yy) |
|
| Hold old is he/she? (e.g. 34) |
|
| What type of Licence does he/she hold? |
|
| How Long has he/she held this licence? |
|
| What is his/her marital status? |
|
| What is his/her main occupation? (e.g. Teacher) |
|
| What line of business is this in? (e.g. education) |
|
| Does he/she have any physical disabilities or infirmities? |
|
| If Yes to the above, please enter details here. |
|
| What experience does this driver have of driving this type of car? |
|
| Is this driver the main driver of the vehicle |
|
| What does this driver use as his/her daily vehicle |
|
|
| Claims Details |
| Has the driver had any accidents or claims in the last FIVE years, regardless of blame? (If there are more than two, please continue in additional details box at the end!) |
|
| Date of 1st Claim |
|
| How much was paid out for this claim? |
|
| Were you responsible for this? |
|
| What were the circumstances of this claim? |
|
| Date of 2nd Claim |
|
| How much was paid out for this claim? |
|
| Were you responsible for this? |
|
| What were the circumstances of this claim? |
|
|
| Convictions |
|
| Has the driver had any convictions? |
|
| Please enter Conviction Dates / Codes / Penalties Received including Fines, Points and Bans |
|
| Will there be any other drivers? |
|
| If Yes to the above, please enter details here |
|
|
| Cover Required |
|
| What cover do you require |
|
| What mileage do you anticipate doing per annum? (Please note that this can be increased during the term of the policy) |
|
| What will you be using the vehicle for? |
|
|
| Overnight Parking / Garaging |
| Where will the vehicle be kept at night? |
|
| Please confirm garaging postcode |
|
|
| How many years No Claims Bonus do you have? |
|
| Is this bonus... |
|
|
| Cover Start Date |
|
| When would you require cover to start? (dd/mm/yy) |
|
| How did you hear about us? |
|
| What is your best quote? (Leave blank if no other quote.) |
|
|
| Any Other Information |
|
| Please give details about any other information which you may think is helpful, or would like to disclose. |
|
|
|
