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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)

  1. (Full description, if Company director state business nature)
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Vehicles details

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Proposer

Other drivers

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

Medical record

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  • PREVIOUS HISTORY
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London Office

57-60 Charlotte Road, London, EC2A 3QT

T: 0207 199 3258

F: 020 8812 3930

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www.insurancetailors.co.uk


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Saturday: closed

Sunday: closed

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