Car Insurance Quotation Form

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Referrer's name:*

Registered with the ICO, all your personal information is protected under the Data Protection Act 2018

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Personal Info

Title*

Mrs

Miss

First Names*

Last Name*

Date of Birth*

House Number/Name*

First Line of Address*

Second Line of Address

Postcode*

Marital status*

Employment Status*

What's your main occupation?

What industry is this occupation in?

What type of student are you?

Which course are you studying?

Are you a homeowner?*

Yes

Do you have any children under 16 years old?*

Yes

___________________________

Contact Details

Phone*

Driving History

Type of licence do you have?*

Would you like to enter your driving licence number?

Yes

This may reduce your premium.

Please enter your 16-character GB driving licence number

How long have you held licence *

What date was your licence obtained?

Do you have any DVLA-reported medical conditions or disabilities?*

Any additional driving qualifications

What date was qualification obtained?

Were you born in the UK?

Yes

What year did you last become a UK resident?*

Use of any other vehicles*

Do you have any unspent NON-Motoring Criminal Convictions?

Yes

Claims & convictions

Any motor accidents or claims in the last 5 years?

Yes

Accident 1

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

Date*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 2

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

Date*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 3

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

Date*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 4

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

Date*

Cost

Who was at fault?*

Any Injuries

Yes

Any motoring convictions, driving licence endorsements or fixed penalty points within the last 5 years?

Yes

Conviction 1

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Add Another Conviction

Conviction 2

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Add Another Conviction

Conviction 3

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Add Another Conviction

Conviction 4

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Vehicle Details

Do you know the car registration number?

Yes

Registration Number*

Car’s make and model

Manufacturer

Model

Registration Year

Alarms - Immobiliser

Number of Seats

Number of Doors

Engine Size (CC)

Transmission

Manual

Automatic

Estimated car value

Does the vehicle have any modifications?

Yes

What type of modifications?

What is the detail of the modification?

Have you purchased the car?

Yes

Date of purchase*

Registered Keeper*

Legal owner*

Is the car impounded with the police?

Yes

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Vehicle Usage

Where's the car kept during the day?*

Where's the car kept overnight?

Is the vehicle kept at the same address?*

Yes

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?*

Yes

What is the name of the insurer?

Use of vehicle*

Estimated annual mileage

This includes the mileage for any additional drivers

Type of Cover*

Any no claims discount?*

What voluntary excess would you like?

How do you normally pay for insurance?

Please provide your Current/Previous Insurer’s name

This may reduce your price

How much was the renewal price with the previous insurer ?

When do you want cover to start?*

Additional Drivers

Would you like to add an additional driver?

Yes

Additional Driver (1) Details

Title*

Mrs

Miss

Relationship to Proposer/Policy Holder*

First Names*

Last Name*

Date of Birth

Marital Status*

Employment Status*

Occupation & Business Type

Type of licence do you have?

How long have you held licence *

Do you have any DVLA-reported medical conditions or disabilities?*

Were you born in the UK

Yes

What year did you last become a UK resident?*

Use of any other vehicles*

Do you have any unspent NON-Motoring Criminal Convictions?

Yes

Any motor accidents or claims in the last 5 years?

Yes

Any motoring convictions, driving licence endorsements or fixed penalty points within the last 5 years?*

Yes

Would you like to add another additional driver (2)

Yes

Accident 1

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 2

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 3

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 4

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Additional Driver (2) Details

Title*

Mrs

Miss

Relationship to Proposer/Policy Holder*

First Names*

Last Name*

Date of Birth

Marital Status*

Employment Status*

Occupation & Business Type

Type of licence do you have?

How long have you held licence *

Do you have any DVLA-reported medical conditions or disabilities?*

Were you born in the UK

Yes

What year did you last become a UK resident?*

Use of any other vehicles*

Do you have any unspent NON-Motoring Criminal Convictions?

Yes

Any motor accidents or claims in the last 5 years?

Yes

Any motoring convictions, driving licence endorsements or fixed penalty points within the last 5 years?*

Yes

Would you like to add another additional driver (3)

Yes

Accident 1

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 2

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 3

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 4

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Additional Driver (3) Details

Title*

Mrs

Miss

Relationship to Proposer/Policy Holder*

First Names*

Last Name*

Date of Birth

Marital Status*

Employment Status*

Occupation & Business Type

Type of licence do you have?

How long have you held licence *

Do you have any DVLA-reported medical conditions or disabilities?*

Were you born in the UK

Yes

What year did you last become a UK resident?*

Use of any other vehicles*

Do you have any unspent NON-Motoring Criminal Convictions?

Yes

Any motor accidents or claims in the last 5 years?

Yes

Any motoring convictions, driving licence endorsements or fixed penalty points within the last 5 years?*

Yes

Would you like to add another additional driver (4)

Yes

Accident 1

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 2

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 3

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 4

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Additional Driver (4) Details

Title*

Mrs

Miss

Relationship to Proposer/Policy Holder*

First Names*

Last Name*

Date of Birth

Marital Status*

Employment Status*

Occupation & Business Type

Type of licence do you have?

How long have you held licence *

Do you have any DVLA-reported medical conditions or disabilities?*

Were you born in the UK

Yes

What year did you last become a UK resident?*

Use of any other vehicles*

Do you have any unspent NON-Motoring Criminal Convictions?

Yes

Any motor accidents or claims in the last 5 years?

Yes

Any motoring convictions, driving licence endorsements or fixed penalty points within the last 5 years?*

Yes

Accident 1

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 2

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 3

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Add Another Claim

Accident 4

What type of incident was it?

Accident

Windscreen glass

Theft

Malicious damage

Storm or flood

Fire

dd/mm/yyyy*

Cost

Who was at fault?*

Any Injuries

Yes

Conviction 1

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Add Another Conviction

Conviction 2

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Add Another Conviction

Conviction 3

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Add Another Conviction

Conviction 3

Date of driving conviction or offence (if conviction still pending)*

Conviction Code*

Code:

Points incurred

Fine incurred (if no fine, enter 0)

Ban length in months (if no ban, enter 0)

Was the driver breathalysed?

Yes

What was the breathalyser reading?

Was the offence accident-related?

Yes

Additional comments

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