Car Insurance Form

How did you hear about us?

If by a friend, family or referrer please state their name and number.

Name:

Number:

Personal Info

Title: *

First Name: *

Surname: *

Birthday:*

Date:

Month:

Year:

House Number/Name: *

First Line of Address: *

Postcode: *

Marital Status: *

Employment Status: *

What is your occupation:

What is the nature of the business:

If you are a Student, which subject are you studying:

If Self Employed, nature of Business/ Sole Trader or Limited Company:

Company name:

Home Owner: *

Any Children Under 16: *

Contact Info

Email:

Mobile: *

Phone:

Please contact me via:

Driving History

Type of License: *

Period Licence held for: *

What date was the Licence obtained:*

Date:

Month:

Year:

Please enter your 16-character driving licence number:

DVLA medical conditions or disabilities:*

Were you born in the UK:*

If No, when did you last become a UK resident:

Date:

Month:

Year:

Use of any other vehicles:*

Non motoring criminal convictions:

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years: *

Yes

No

Motor Accidents or Claim Details

1

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

2

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

3

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

4

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions: *

Yes

No

Motor Conviction, Fixed Penalty or Disqualification Details

1

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

2

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

3

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

4

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

Vehicle Details

Vehicle Registration: *

Tick this box if you don't know the vehicle registration

Car Details

Manufacturer:

Model:

Registration Year:

Alarms - Immobiliser:

Number of Seats:

Number of doors:

Engine Size (CC):

Transmission:

Approximate value of the car right now:

Does the vehicle have any modifications: *

Yes

No

Please advise on what modifications have been made to the car

Date of purchase:*

Date:

Month:

Year:

Not yet purchased

Registered Keeper:*

Legal Owner:*

Is the car impounded with the police?

Vehicle Usage

Where is the vehicle kept during the day:*

Where is the vehicle kept overnight:*

Is the vehicle kept at the same address:*

If No, what is the full address of where the vehicle is kept:

Have you or any of the drivers ever had insurance declined, cancelled or special terms imposed:*

Use of vehicle:*

Estimated Annual Mileage:*

Type of Cover:*

Any no claims discount:*

How did you earn your no claims discount:

Was this NCD earned in the UK:

Would you like to protect your NCD:

What voluntary excess would you like:*

How do you normally pay for insurance:*

Please provide your Current/Previous Insurer name:

When would you like the policy to start:*

Date:

Month:

Year:

Additional Driver

Would you like to add an additional driver

Yes

No

Additional Driver (1) Details

Title: *

First Name: *

Surname: *

Birthday:*

Date:

Month:

Year:

Marital Status: *

Employment Status: *

What is your occupation:

What is the nature of the business:

If you are a Student, which subject are you studying:

Type of License: *

Period Licence held for: *

What date was the Licence obtained:*

Date:

Month:

Year:

Please enter your 16-character driving licence number:

DVLA medical conditions or disabilities:*

Were you born in the UK:*

If No, when did you last become a UK resident:

Date:

Month:

Year:

Use of any other vehicles:*

Non motoring criminal convictions:

If you want a price using the second driver as Policy Holder, then please provide their address:

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years: *

Yes

No

Motor Accidents or Claim Details

1

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

2

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

3

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

4

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions: *

Yes

No

Motor Conviction, Fixed Penalty or Disqualification Details

1

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

2

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

3

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

4

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

Would you like to add an additional driver

Yes

No

Additional Driver (2) Details

Title: *

First Name: *

Surname: *

Birthday:*

Date:

Month:

Year:

Marital Status: *

Employment Status: *

What is your occupation:

What is the nature of the business:

If you are a Student, which subject are you studying:

Type of License: *

Period Licence held for: *

What date was the Licence obtained:*

Date:

Month:

Year:

Please enter your 16-character driving licence number:

DVLA medical conditions or disabilities:*

Were you born in the UK:*

If No, when did you last become a UK resident:

Date:

Month:

Year:

Use of any other vehicles:*

Non motoring criminal convictions:

If you want a price using the second driver as Policy Holder, then please provide their address:

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years: *

Yes

No

Motor Accidents or Claim Details

1

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

2

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

3

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

4

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions: *

Yes

No

Motor Conviction, Fixed Penalty or Disqualification Details

1

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

2

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

3

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

4

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

Would you like to add an additional driver

Yes

No

Additional Driver (3) Details

Title: *

First Name: *

Surname: *

Birthday:*

Date:

Month:

Year:

Marital Status: *

Employment Status: *

What is your occupation:

What is the nature of the business:

If you are a Student, which subject are you studying:

Type of License: *

Period Licence held for: *

What date was the Licence obtained:*

Date:

Month:

Year:

Please enter your 16-character driving licence number:

DVLA medical conditions or disabilities:*

Were you born in the UK:*

If No, when did you last become a UK resident:

Date:

Month:

Year:

Use of any other vehicles:*

Non motoring criminal convictions:

If you want a price using the second driver as Policy Holder, then please provide their address:

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years: *

Yes

No

Motor Accidents or Claim Details

1

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

2

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

3

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

4

Type:

Date of Accident:

Date:

Month:

Year:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions: *

Yes

No

Motor Conviction, Fixed Penalty or Disqualification Details

1

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

2

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

3

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

4

Conviction Code:

Date of Conviction:

Date:

Month:

Year:

Points:

Fine(£) - if any:

Ban(months) - if any:

Additional Comment

Car Insurance Quotation Form

Car Insurance Quotation Form

Personal Info

Contact Info

Driving History

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4

Vehicle Details

Car Details

Vehicle Usage

Additional Driver

Additional Driver (1) Details

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4

Additional Driver (2) Details

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4

Additional Driver (3) Details

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4