| Full Name |
* |
|
| Date cover to start from for 12 months |
* |
|
| Home Address |
* |
|
| Postcode |
* |
|
| Date of Birth |
|
e.g.1st March 1972 = 01.03.72 |
| You hold which British Licence? |
|
|
| If full, how long have you held it? |
|
years |
| Do you have any disabilities? |
|
If YES please give details
(i.e. diabetes, epilepsy etc)
|
| Have you had any driving convictions? |
|
|
Details of convictions:
(Please state date of conviction, followed by conviction code, number of points on licence and amount £ of fine) |
|
1
2
|
| Daytime Phone Number |
* |
|
| Mobile Number |
|
|
| Occupation |
|
|
| Type of business in which you are employed? |
|
|
| What Part-time job do you have, if any? |
|
|
| Self Employed? |
|
if yes, date that liability insurance due:
|
| |
body type
(eg van, pickup, tipper) |
|
|
| petrol or deisel: |
|
|
| Make |
* |
|
| Model (full description please) |
* |
|
| Left or right hand drive |
|
|
| Year of manufacture |
|
|
| Engine capacity |
|
cc |
gross vehicle weight
(if a van or commercial vehicle) |
|
kgs |
Approximate value of your vehicle |
|
Value £
|
| Has your vehicle been modified in any way? |
|
If YES, details:
|
| Where is your vehicle normally kept overnight? |
|
postcode
|
| Make & Model of fitted immobiliser or alarm |
|
|
| number of seats |
|
|
| current mileage of vehicle |
|
|
| Cover insured for: |
|
|
| Drivers other than yourself who will drive your vehicle: |
|
Name 1
Date of Birth
e.g.1st March 1975 = 01.03.75
Type of licence held?
Full
Provisional
for
years
Occupation
|
| |
|
Name 2
Date of Birth
e.g.1st March 1975 = 01.03.75
Type of licence held?
Full
Provisional
for
years
Occupation
|
| Have you had any accidents or claims during the last five years? |
|
If YES advise date, circumstances of loss, amounts involved and name of driver
|
Type of cover required? |
|
|
| What do you use your vehicle for? |
|
Details of business use / nature of goods carried:
|
| Number of years of no claims bonus? |
|
|
| Excess required |
|
|
| when would you like to be contacted? |
|
normal office are:
8 am - 5.45 pm Monday - Friday
8 am - 11.30 am Saturday |
| best contact Number |
* |
|
| E-mail Address |
* |
|
| |
|
|
