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1. THE OWNER
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Title
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First
Name
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Surname
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Address
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Occupation
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Are
you the sole owner of the vehicle?
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Name
& Address of other owner if applicable
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Is
the vehicle the subject of a loan / mortgage?
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Name
& Address of lender / mortgagee
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Is
driving to be open or restricted?
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2. DRIVER INFORMATION
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Will
the owner be driving?
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If
YES, state date of birth (DD/MM/YYYY)
and continue at 3.
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If
no, who is the main driver:
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First
Name
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Surname
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Address
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Occupation
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Date
of Birth (DD/MM//YYYY)
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Relationship
to owner
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3. DRIVER'S LICENSE INFORMATION
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Full
or provisional
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Where
issued
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Date
first full license issued (DD/MM//YYYY)
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CONVICTIONS
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Have
you ever been convicted of any offences in connection with any
motor vehicle or is any prosecution pending?
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Have
you ever received any traffic tickets or points in connection
with any motor vehicle?
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If
yes, complete below:
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Date
(DD/MM//YYYY)
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Penalty
Imposed
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Details
of Offence
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Do
you suffer from any physical disabilities? E.g. defective vision
or hearing, diabetes, fits etc ...
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If
yes, give details
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Have
you previously held motor insurance?
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Insurance
Company (if known)
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Period
of Insurance (DD/MM//YYYY)
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to
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Type
of Vehicle
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Has
proposal ever been declined or special terms imposed?
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If
yes, give details
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Are
you entitled to a No Claim Bonus from your previous insurance
company ?
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If
so, state percentage, if known (proof will be required at inception
of cover)
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%
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6.
OTHER DRIVER INFORMATION
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Are
there additional named drivers?
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If
yes, complete below:
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First
Name
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Surname
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Address
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Occupation
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Date
of birth (DD/MM//YYYY)
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Relationship
to Proposer / Owner
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Have
there been any accidents, fires, thefts or other claims
during the last 3 years in connection with any motor vehicle
owned or driven by you or any other person who to your knowledge
will drive this vehicle? If yes, give details below.
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Date
of accident / loss (DD/MM/YYYY)
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Name
of driver (if applicable)
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Description
of accident / loss
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Cost
of Damage to Own Vehicle
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Paid
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Outstanding
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Cost
of Third party Damage / Injury
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Paid
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Outstanding
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Copy
of registration certificate and fitness to be provided at inception
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Year
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Make
and Model
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Suffix
(e.g. GL, GLX etc.)
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Body
(e.g. saloon, sedan, coupe, s/wagon)
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Engine
Size
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Registration
Number
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Chassis
Number
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Engine
Number
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Date
Purchased (DD/MM/YYYY)
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Price
Paid
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Registered
No. of seats
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Domestic
Import (Deportee)
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Accessories
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(Check where applicable)
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Air Conditioning
Sport Wheels
Cruise Control
Power Seats
Central Locking
Power Windows
Audio Equipment
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Has
vehicle been modified?
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If
yes, state in what manner
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Type
of cover required
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Value
of Vehicle
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The
use of the car
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Social, domestic and pleasure
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Travelling to and from normal place of work
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Sales / Commercial Travel
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State
all other purposes
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9.
ADDITIONAL VEHICLES
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Do
you wish to insure an additional vehicle
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10.
CONTACT INFORMATION
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Please
select how you would like to receive your quotation and enter
the relevant contact details
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By
Email
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By
Telephone
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By
Post (Address)
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DECLARATION
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The
information given above for the purposes of this quotation will
be incorporated into your contract if accepted and you will be
required to sign a declaration attesting to the validity of all
statements given.
****Additional discounts are available
if
your vehicle have been valuated by an approved valuator or if you or your spouse have other vehicles with General Accident.
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*** SECTION 2 - TO BE COMPLETED ONLY IF INSURING AN ADDITIONAL
CAR ***
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