Section 1 Proposer's Personal Details

Title

Mr Mrs Miss Ms Dr

Forename(s)

Surname

Email

House Number / Name

Post Code

Daytime contact telephone number

Date of Birth e.g. 23/07/1972

/ /

Marital Status

Married Single Common-law Divorced Widowed

Occupation - Industry e.g. Building

Precise Occupation e.g. Bricklayer

Employment Status

Employed Self Employed

How many full years resident in the UK?

Type of Licence(s) held (select all that apply)

Full UK (Car) Full UK (Motorcycle) Provisional UK Foreign International Restricted

Date Passed Driving Test, for the type of vehicle you wish to insure
e.g. 23/07/1972

/ /

Section 2 About Your Vehicle

Manufacturer e.g. Ford

Precise Model e.g. Transit

Body Style

Lorry Van Pick Up Tipper Refrigerated Double cab Other

Year of Manufacture

Fuel

Petrol  Diesel  Other

Engine size / Cylinder Capacity e.g. 1600cc

Approximate value of the vehicle

Where is the vehicle usually parked overnight? (Assumes vehicle kept at home address)

Garaged Private Land e.g. driveway On Road

Approximate annual mileage

Section 3 Use, Cover, and Drivers Required

Who is the main driver?

Use required

Carriage of own goods Haulage Domestic Social and Pleasure

Level of Cover

Fully Comprehensive Third Party Fire and Theft Third Party Only

How much no claims bonus can you prove

Nil 1 year 2 years 3 years 4 years 5 years 6 years 7 years +

Date cover required eg. 10/12/2002

/ /

Who is to drive the vehicle

Proposer only Proposer and spouse Proposer and common law spouse Named drivers Any driver over 30 Any driver over 25 Any driver

Section 4 Additional Drivers

Title

1 Mr Mrs Miss Ms Dr

2 Mr Mrs Miss Ms Dr

3 Mr Mrs Miss Ms Dr

Forename(s)

Surname

Relationship to the proposer e.g. spouse

Marital Status

1 Married Single Common-law Divorced Widowed

2 Married Single Common-law Divorced Widowed

3 Married Single Common-law Divorced Widowed

Occupation - Industry e.g. Building

Precise Occupation e.g. Bricklayer

Date of Birth eg. 10/12/2002

1 / /

2 / /

3 / /

How many full years resident in the UK?

Type of Licence(s) held (select all that apply)

1 Full UK (Car) Full UK (Motorcycle) Provisional UK Foreign International Restricted

2 Full UK (Car) Full UK (Motorcycle) Provisional UK Foreign International Restricted

3 Full UK (Car) Full UK (Motorcycle) Provisional UK Foreign International Restricted

Date Passed Driving Test, for the type of vehicle you wish to insure (dd/mm/yy)

/ /

/ /

/ /

Section 5 Claims, Convictions & Disabilities

Have any of the drivers had any convictions in the past five years, or is any prosecution pending? (Please note that all drink or drug related convictions e.g. DR10 within the last eleven years, and any convictions involving a fine e.g. SP30 within the last five years, must be disclosed.)

Yes  No

Please provide conviction details, including the driver's name, the conviction code e.g. SP30, the date of conviction, the lenght of any ban in months, the number of penalty points awarded and the amount of any fine in pounds.

Have any of the drivers been involved in any motor incidents or claims in the last five years (Whether their fault or not)?

Yes  No

Please provide incident/claim details in the box below, including the driver's name, the incident circumstances, the date of the claim and the approximate costs involved

Do any of the above drivers suffer from any medical conditions or disabilities that affect their driving and/or require them to notify the DVLA e.g. diabetes, epilepsy?

Yes  No

Please provide details , including the driver's name, the nature of the disability/infirmity, details of any measures/medication taken to counter the condition, how long the condition has existed and whether the DVLA have been notified.

Section 6 Other Information

How would you like us to contact you?

Telephone E-mail Post

How did you find/hear about us?

Existing client Old Client Recommended Saw office Thompson local Yellow pages Newspaper Search engine