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MOTOR QUOTE FORM APPLICATION

This form is designed to capture the information on which the contract of insurance will be based. All information you provide must be true and correct to the best of your knowledge and belief. Any information that is likely to influence insurers in the assessment or acceptance of your application, such as intended unoccupancy of your home, must be disclosed. If you are in any doubt as to whether a fact is relevant you must disclose it.

1. Proposer details

2. Cover requirements

3. Previous history

3. Previous history (2)

4. Driver details

5. Claim history (Last 5 years)

Title
First name
Surname
Date of birth
Occupation (Full description, if Company director state business nature)
Telephone number
Email address
Postal address

Current insurer
Inception / Renewal date
Target premium
Number of vehicles in household

Breakdown cover

UK

EUROPEAN

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Have you or anyone living with you at the premises to be insured;

Ever had a proposal for insurance declined?

Please give us further details in the space below

Ever had a renewal refused?

Please give us further details in the space below

Ever been convicted for any non-motor criminal offenses?

Please give us further details in the space below

Ever had any special terms or conditions imposed?

Please give us further details in the space below

Ever had insurance cancelled or declared void?

Please give us further details in the space below

Been cautioned for or charged but not yet tried for any non-motor offences?

Please give us further details in the space below

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Vehicles details

Please note that you can add more than one vehicle

Registration number *

Make

Exact model (e.g LX)

Engine size (cc)

Year of make

Year of purchase

Transmission type

Drive

Fuel type

Body type

Modified

Current value

Security (Type of tracking etc)

Vehicle location at night

Postcode of night location

Annual mileage

Register owner and keeper

Main driver

Other drivers

Class of use (social / domestic)

Number of years no claims bonus

NCB protection required

Voluntary excess

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Proposer

Name
Date of birth
Occupation
Employer's business
Address
Marital status
Type of licence
Years licence held
Years resident in UK
Relationship to insured

Other drivers

Name
Date of birth
Occupation
Employer's business
Address (if different)
Marital status
Type of licence
Years licence held
Years resident in UK
Relationship to insured

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Driver's name
Claim date
Own damage costs
3rd party costs
Claim description

Convictions (last 5 years and all bans, regardless of date)

Driver's name
Conviction code
Conviction date
Penalty points
Fine
Ban
Blood alcohol level

Medical record

Does any driver have any defect in vision, hearing, mental or physical infirmity, disorder or disease (including diabetes, epilepsy or heart condition)?

Driver
Medical condition
Date first diagnosed
DVLA advised
Restriction on licence

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