MOTOR INSURANCE PROPOSAL FORM 

Please fully complete the form below and we will respond promptly.

Full Name  
Email Address    
Tele. Number       
Address Line 1    
Address Line 2
Address Line 3  
Post Code      
Sex      Female  Male 
Date of Birth   
Occupation 
Licence   Full    Provisional
How long have you held a driving Licence ?  YEARS

YOUR INSURANCE COVER

Type of Car   ( Make/model/size)   
Reg. No. Number 
Year Made  
Current Value 
Do you have an alarm fitted ?  YES    NO
Immobiliser ?    YES    NO
Has there been any modifications to the standard spec ? YES    NO
If yes please enter details      
Overnight Parking 
Cover Class of use 
Drivers 

DETAILS OF DRIVERS

Driver No.

Name

Age
1
2
3
 
Have you or any driver had an accident or loss in the last 5 years?  YES    NO
Have you or any driver been convicted of any motoring offences in the last 5 years or had a licence suspended in the last 11 years?    YES    NO
Do you or any driver suffer from any physical or mental disabilities, diabetes, epilepsy, heart conditions or regularly take prescription medication?  YES    NO
If  you have answered YES to any of the question above please give details, including dates and cost of accidents and convictions.
Annual Mileage  
No Claims Bonus ?  YES    NO
No of years    
Protect No Claims ? YES
Legal Expenses Cover ?        YES    NO
Date of Renewal 
Have you had any other quotes  ?  If so please let us know how much and the company that quoted it.