Serving the public since 1975

Motor Insurance

Details
Title
Sex
Forename(s)
Surname
Telephone Contact number
Email
Postcode where vehicle is kept
Make of vehicle
Exact model
Year of make
Engine size
Value £
Date Purchased
Where vehicle is kept
Are there any cosmetic, mechanical, or engine alterations from original specifications?
If YES please state full details of all modifications in the box opposite
Does your vehicle have a Thatcham category 1 or 2 immobiliser fitted?
Estimated annual mileage
Cover required
Drivers required
Use of vehicle
How many years - no claims bonus
Would you like protected no claims bonus
At least 4 years required to qualify.
Name of current insurer and expiry date

Drivers required
Drivers Name Occupation Date of Birth Type of current UK
driving licence		 Date passed test
Proposer
Driver #2
Driver #3
Driver #4

Details

Do you or any named driver suffer from any loss of or use of limb/eye/defective hearing or sight not corrected by hearing aids/spectacles or any other infirmity.
If yes give details. Yes No

Have there been any accidents, claims or losses whether to blame or not during the past 5 years in respect to any motor vehicle owned or driven by you or any named driver. Yes No

If yes state for each claim date, type of claim e.g. accident/theft, amount of damaged caused to yourself and the third party if applicable and whether it was settled 100% in your favour.

Have you or any driver ever been convicted of any offence including any fixed penalty in connection with any motor vehicle or any criminal conviction.?.
Yes No

If yes state for each offence conviction date and incident date, conviction code, points/fine/ban received and alcohol reading if applicable.
When is your insurance required by? / /
What is your current quote in £.?
Are you a member of a Motoring Club? Yes No       If yes state which Club


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