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To obtain a quotation simply fill in the following form and one of our expert staff will contact you as soon as possible.
Broker Details
Broker Name:
Tel No:
Fax No:
E-mail:
Proposer Details
Title
Select
Mr
Mrs
Miss
Ms
Initials:
Surname:
Date of Birth:
Company/Trading name:
Tel No:
Fax No:
E-mail:
Business Description/Occupation:
Charity No (If registered charity):
Vehicle, ownership & Cover Details:
Please select the number of vehicles you wish to quote on:
Select
1
2
3
4
5
Vehicle One
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle One
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Two
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle One
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Two
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Three
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle One
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Two
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Three
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Four
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle One
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Two
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Three
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Four
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
Vehicle Five
Make/Model:
Registration No:
Year of make:
Estimated value:
Seating Capacity:
Annual Mileage:
Overnight postcode:
NCD:
Overnight Parking:
Select
Road
Drive
Garage
Protected NCD:
Select
Yes
No
Cover Required
Select
Comprehensive
Third-Party, Fire & Theft
Excess:
If the vehicle(s) are more that 15 years old, what maintenace regime does the proposer have in place:
Are seats are forward facing & fitted with seat belts?
Select
Yes
No
All vehicles are owned and registered in the proposers name?
Select
Yes
No
Details...
Are all vehicles free from modifications and adaptations (other then professional fitted tail lifts)
Select
Yes
No
Details...
Use
Vehicle Use
Select
Social, domestic and pleasure purposes (including commuting to a permanent place of work)
Business purposes (excluding hire & reward)
Operating under a section19 permit of the Transport Act 1985
Public Hire
Private/Contract hire
Amount of contract work:
%
Plated:
Select
Yes
No
Are any vehicles operated overseas, if so, number of trips/days per annum and
countries visited
Hotel/Travel Industries
Estimated percentage of passengers carried who may be high profile clientel/ celebraties/ USA or Canadian citizens
%
Driver Details
Restrictions
Select
Proposer or one named if company
Proposer and domestic partner
Proposer plus 4 named drivers
Any anthorised driver
Driver 1
Name:
DOB
Occupation:
Years full UK licence held:
PCV/PSV licence?
Select
Yes
No
Minibus/MPV Driving Years Experence
Disabilities/Medical Conditions
Convictions (Within the past 5 years)
Accidents/claims/Losses (Within the past 3 years)
Main vehicle driven
Driver 2
Name:
DOB
Occupation:
Years full UK licence held:
PCV/PSV licence?
Select
Yes
No
Minibus/MPV Driving Years Experence
Disabilities/Medical Conditions
Convictions (Within the past 5 years)
Accidents/claims/Losses (Within the past 3 years)
Main vehicle driven
Driver 1
Name:
DOB
Occupation:
Years full UK licence held:
PCV/PSV licence?
Select
Yes
No
Minibus/MPV Driving Years Experence
Disabilities/Medical Conditions
Convictions (Within the past 5 years)
Accidents/claims/Losses (Within the past 3 years)
Main vehicle driven
Driver 2
Name:
DOB
Occupation:
Years full UK licence held:
PCV/PSV licence?
Select
Yes
No
Minibus/MPV Driving Years Experence
Disabilities/Medical Conditions
Convictions (Within the past 5 years)
Accidents/claims/Losses (Within the past 3 years)
Main vehicle driven
Driver 3
Name:
DOB
Occupation:
Years full UK licence held:
PCV/PSV licence?
Select
Yes
No
Minibus/MPV Driving Years Experence
Disabilities/Medical Conditions
Convictions (Within the past 5 years)
Accidents/claims/Losses (Within the past 3 years)
Main vehicle driven
Driver 4
Name:
DOB
Occupation:
Years full UK licence held:
PCV/PSV licence?
Select
Yes
No
Minibus/MPV Driving Years Experence
Disabilities/Medical Conditions
Convictions (Within the past 5 years)
Accidents/claims/Losses (Within the past 3 years)
Main vehicle driven
Do any angency or casual drivers drive any of the vehicles?
Select
Yes
No
Previous Insurance
Existing Insurer
Select
Allianz Cornhill
AXA
Britt
Co-Op Insurance Services
Equity Red Star
Highway
NFU
Norwich Union
Royal and Sun Alliance
Zurich
Other
Date cover required
Target/Renewal Premium
Are you the Holding Broker?
Select
Yes
No