FLEET INSURANCE QUOTE

1. Name of Proposer and Trading Title:
Age of proposer if sole trader:
2. Address of the premises:
Post Code:	Tel. Number:
e-mail (if you have any):
3. Description of Business (Occupation & Nature of all Business engaged in) :
4. Date Established:
5. Type of premises:	Other
6. Have any of the vehicles shown been altered in any way including electronically (e.g. engine or body modifications, special or non-standard equipment, non-standard wheels, or are any of them Left Hand Drive)?	Yes No
7. Has any vehicle audio/telecommunication equipment exceeding a value of £500?	Yes No
8. Has any vehicle been fitted with any security or tracking devices?	Yes No
If "yes" 6,7 or 8, please give details:
9. Are all vehicles owned by you and registered in your name?	Yes No
10. Trailer cover - if cover is required for trailers whilst attached to or detached from the insured vehicles give details of number owned, makes, serial numbers and values.
11. USES
a) Will any vehicle be used for haulage purposes outside the United Kingdom?	Yes No
b) Will any vehicle be used in Northern Ireland or Eire?	Yes No
c) Will any vehicle be used “airside” in any airfield or aerodrome?	Yes No
d) Will any vehicle carry toxic, explosive, corrosive or inflammable goods?	Yes No
e) Will any vehicle be used to carry passengers for private or public hire?	Yes No
f) Will any vehicle be hired from a rank or stand, have radio communication or cruise for fares?	Yes No
If you have answered yes to any part of question 11, please give details:

12. Drivers
a) Do you or any person who may drive have defective vision or hearing (not corrected by glasses or hearing aid), any physical, mental, alcoholic or nervous disorder, or heart, diabetic or epileptic condition or other complaint, had blackouts or fits, or regularly take any prescribed medication?	YES NO

If "yes", please give details including names of persons, nature of complaints, years stabilised if appropriate and details of medication. Also confirm that DVLA have been informed and advise whether your/their driving license is restricted as a result.

b) Have you or has any person who drive:

	(i) had any motoring convictions in the last 5 years or are there any prosecutions pending or police enquiries outstanding (including fixed penalty offences)? Parking offences or a single speeding offence may be ignore	YES NO
	(ii) had any criminal convictions (or been charged with a criminal offence but not yet tried)?	YES NO

If YES give names of persons. offences, dates, penalties and points

c) Have you or any person who may drive ever been disqualified from driving?

YES NO

If YES give names of persons, offences, dates, penalties and periods of disqualification

d) Do you examine the driving licences of all new employees for validity and motoring convictions?	YES NO
e) Do you examine the driving licence of all employees annually to check they are valid and whether there are motoring Convictions?	YES NO
f) If so, do you undertake to advise us of all motoring convictions and any restriction which may be imposed by the Authorities?	YES NO

13. INSURANCE HISTORY

a) State name of previous/present insurer showing branch, policy number and renewal date.

b) Has any company or underwriter at any time in respect of motor insurance declined to insure you, cancelled your policy, refused to renew, required increased premium or special terms?	YES NO
c) Have there been any accidents, thefts or losses (whether covered by insurance or not and regardless of blame) during the past 3 years in connection with any vehicle owned or driven by or in the charge of you or any other person who to your knowledge may drive?	YES NO

If "yes" b or c, please give details

14. Vehicle Schedule - Please list below details of all vehicles to be insured

NO	Make and Model	Type of body (eg: saloon, hatchback) and number of seats	Engine size (c.c)	Gross vehicle weight	Year of Make	Value	Registration No	Cover	Table. Class of Use
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29


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