CAR QUOTE
   
1. Name:
2. Address:
Post Code:
        Tel. Number:  
e-mail (if you have any):
 
3. Date of Birth
4. Sex:             Marital Status
5. License type: How many years held :
6. Occupation:
7. Home-owner:

8. Are you resident in the UK for life?

if no, please provide full details
   
   
9. Vehicle registration number:
10. Vehicle make (i.e: Mercedes Sprinter):
11. Vehicle model (i.e:GTI)
12. Body type (i.e: Hatchback etc)
13. Year of manufacture:
14. Engine size: (cc)
15. Value:
15a. Where is the vehicle kept overnight?
16. Colour
17. Current mileage reading:
 
18. Any modifications from standard: Yes No
19. Security (alarm, immobiliser) ? Yes No

if "Yes" to 18 or 19 please provide details:
 

 
     
20. Cover required: Comprehensive
  Third Party Fire & Theft Yes No
  Third Party Only Yes No
     
21. Number of years no claims discount:  
22. Previous insurers name:  
23. Use required:    
  Social Domestic & Pleasure
  Business use required Yes No
If you business use is required, please provide annual business mileage:
Please provide annual personal mileage:

24. Authorised driving:

Driver's name
1. First driver:    
Driver Name: Date of Birth:   Occupation:
Level of use:   License type: Years License Held:
Usage:
Relation to policyholder  
     
2. Second driver:    
Driver Name: Date of Birth:   Occupation:
Level of use:   License type: Years License Held:
Usage:
Relation to policyholder  
     
3. Third driver:    
Driver Name: Date of Birth:   Occupation:
Level of use:   License type: Years License Held:
Usage:
Relation to policyholder  
     
4. Fourth driver:    
Driver Name: Date of Birth:   Occupation:
Level of use:   License type: Years License Held:
Usage:
Relation to policyholder  
     
5. Fifth driver:    
Driver Name: Date of Birth:   Occupation:
Level of use:   License type: Years License Held:
Usage:
Relation to policyholder  
     
 
25. Have you or any of the drivers had any claims in the last 5 years?  
if "Yes" please provide details: (date of claim, description, payments to third party (if known) & own payment)
26. Have you or any of the drivers had any convictions, whether motor related or not, in the last 5 years?   Yes No
if "Yes" please provide details: (date of conviction, type of conviction, penalty points and fine details)
27. Have you or any of the drivers insured on this policy been refused insurance, or had special terms imposed?   Yes No
if "Yes" please provide details:

 

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