Motor Quotation Form

Please complete the form below with as much information as possible.

We apologise for the number of questions. Please bear with us. The answers to the questions will enable us to obtain the maximum amount of discount to the premium.

Once we receive the information we will input it into our quotation system to obtain the best possible quotation using our substantial panel of top UK insurers.

We will then E-Mail the quotation to you as soon as possible.

Privacy Statement

We would advise you that the information provided will only be used for the purposes of providing you with the relevant quotation and none of the information will be passed on to a third party or any other organisation without your prior permission.

1. About You.

Title
Mr Mrs Miss Ms
Tel No(Incl STD Code)
First Name(s)
Fax No(Incl STD Code)
Surname
E-Mail Address
Address
Date of Birth
Town/Village
Occupation
City
Home Owner?
Yes No
County
Married?
Yes No
Post Code
   

2. Cover

From what date would you want cover to start?
Day Month Year
What cover would you require?
Comprehensive TPF&T TP Only
Voluntary excess(Comp cover only)?
£50 £100 £200
Protected bonus?
Yes No
Previous Insurers
Name
Number of years no claims bonus
years

3. Vehicle

Make of vehicle(eg Ford)
Exact model(eg Focus LX)
Engine Size(Cubic capacity)
c.c.
Body Type(eg Hatchback,saloon etc)
Number of seats
Year of manufacture
Value
£
What is vehicle used for?
Is the car left hand drive?
No Yes
Is the car imported(not normally available in UK)?

No Yes If yes give details below:-

Has the car been modified from standard?

No Yes If YES give details below:-

Annual mileage
Where is vehicle kept overnight?
Do you own the vehicle?
Yes No If NO who is owner?
Is the vehicle registered in your name?
Yes No If NO in whose name?

4. Drivers

Please ensure that you disclose details of all drivers under the age of 25 and also all drivers who have had motoring convictions or been involve in motor claims.

Who do you wish to drive the vehicle?

Please give full details below of yourself,members of family and all other persons who may drive the vehicle:

Name

Sex

Male/Female
Date of Birth
Age

Employed or self employed?

Type of business

eg factory,bank etc
Precise occupation
Yourself
1.
2.
3.
4.

 

Driver
Relationship to you

Type of licence ie full,provisional etc
No. of years held
How long resident in UK
Does driver have use of another vehicle?
Yourself
N/A
years
Yes No
1.As above
years
Yes No
2.As above
years
Yes No
3.As above
years
Yes No
4.As above
years
Yes No
Are you the main driver? Yes No If NO who is main driver?
Do you or any other person who may drive have any criminal convictions? No Yes If YES give details
Have you or any other person who will drive your vehicle:-
a)Been convicted of any motoring offence in the last 5 years? No Yes If YES give details below
b)Ever been disqualified from driving? No Yes If YES give details below
c)During the last 5 years had any accident claim,theft or loss? No Yes If YES give details below

 

Name
Date of conviction
Offence code(eg SP30)
Fines
Disqualification period

 

Name
Date of accident/theft or loss
Brief description of circumstances
Cost of claim
Were all costs recovered?
Yes No
Yes No
Yes No

Do you or any person who may drive suffer from any physical or mental infirmity? No Yes

If YES please give details:

Have DVLA been advised? Yes No

Has the driving licence been restricted? No Yes