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| Your Personal Details:
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| Title |
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Forenames * |
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Surname * |
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Home Phone Number * |
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Address |
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| Post Code |
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| Fax Number |
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| Work Phone Number |
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| Email Address |
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| Date of Birth |
(dd/mm/yy)
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| Marital Status |
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| Occupation |
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| Nationality |
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| How long resident in the UK? |
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Type of Licence(s) held
(Select all that apply) |
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Date Passed Driving Test
(for the type of
vehicle you wish to insure) |
(dd/mm/yy)
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| About Your Vehicle
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| Vehicle Type |
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| Manufacturer |
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| Model |
(eg Escort LX) |
| Year of Manufacture |
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| Registration Number |
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| Postcode where vehicle is kept |
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| Gearbox |
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| Fuel |
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| Engine Size |
litres eg 1.1
(1100cc) |
| Is the vehicle left-hand drive? |
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| Where is the vehicle normally kept over night?
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| Value of the vehicle |
£ (Approx)
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| Has the vehicle had modifications? |
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| If Yes, please give details |
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| Does the vehicle have an Immoboliser? |
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| If Yes, what type? |
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| Does the vehicle have an Alarm? |
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| If Yes, what type? |
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| Are there any other vehicles in your household?
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| If yes, who owns the vehicle? |
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| Use and Cover Details
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| Who owns the vehicle? |
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| Who is the main driver? |
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| Use required |
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| Level of Cover |
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| Voluntary Excess |
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| Who is to drive the vehicle? |
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| Years no claim bonus |
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| Do you want your no claims bonus protected?
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| Date of Cover Start |
(eg
01.01.97) |
| Do you require legal expenses? |
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| Additional Drivers
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| Additional Driver One |
| What relationship to the proposer? |
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| Do they own or use another vehicle? |
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| Title |
|
| Forenames |
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| Surname |
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| Occupation |
|
| Date of Birth |
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| Licence Type |
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| Date Passed Driving Test |
(eg
01.01.70) |
| Additional Driver Two |
| What relationship to the proposer? |
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| Do they own or use another vehicle? |
|
| Title |
|
| Forenames |
|
| Surname |
|
| Occupation |
|
| Date of Birth |
|
| Licence Type |
|
| Date Passed Driving Test |
(eg
01.01.70) |
| Details of Persons who will
drive the vehicle |
| Have any of the above drivers had any convictions
in the past five years, or is any prosecution pending?
|
|
| Please note all "DR" (drink/drugs related)
convictions within the last 11 years must be disclosed.
Please put details of all convictions in the box below,
including the Driver's Name, the Code, the
Date of conviction, the length of the Ban
in months, the number of Points on the license,
and the Fine in pounds.
|
| Do any of the above drivers suffer from any
medical conditions or disabilities that affect their
driving? |
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| If Yes, please let us know the driver's
name and details of their
condition/disability |
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| Have any of the above drivers ever been declined
motor insurance? |
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| If Yes, please give details |
|
| Have any of the above drivers had any accidents
or claims in the last three years? |
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| If yes, please give details, including the
Driver's Name, Details of claim, the
Date of the claim, and the Cost of the
claim, if known.
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| If you have already been given a quote, please
enter the figure here |
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| Which insurer was this quote from? |
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| Please give the renewal date of your existing
policy or the commencement date of the new policy
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| Contact Method: |
| How would you like us to contact you?
By Phone By Fax By Email By Post |
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