Van Insurance Quotation Form

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PERSONAL DETAILS

Title *

First Name *

Surname *

Date of birth *

House Number/Name *

Address *

Postcode *

Marital Status *

Employment Status *

If Employed/Self Employed, what is your occupation:

If Employed/Self Employed, what type of business:

Home owner *

Any Children Under 16 *

Contact Info

Email

Phone

Mobile *

Please contact me via

Phone
Text
Email

Driving History

Type of licence *

Period License held for *

If less than 3 years, what date was licence obtained

DVLA medical conditions or disabilities *

Any additional driving qualifications *

If one is selected, what date was qualification obtained

Were you born in the UK

Yes
No

If No, when did you last become a UK resident

Use of any other vehicles

Non motoring criminal convictions

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years

Yes
No

Motor Accidents or Claim Details

1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

2

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

3

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

4

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

Any motor convictions, fixed penalties or disqualifications in the last 5 years * Yes No *

Yes
No

Motor Accidents or Claim Details

1

Conviction Code:

Date of Conviction:

Points

Fine(£) - if any

Ban(months) - if any

2

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months)- if any

3

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

4

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

Vehicle Details

Vehicle Registration *

Approximate value of the van at present?

Manufacturer:

Model

Alarms - Immobiliser

Number of Seats

Number of doors

Engine Size (CC)

Transmission

Manual
Automatic

Fuel type

Body type

Roof Type

Normal Roof
High Roof

Wheel Base

Does the vehicle have any modifications?

Yes
No

Is the van impounded with the police?

Yes
No

Vehicle Usage

Date of purchase *

or Not yet purchased

Where is the vehicle kept during the day *

Where is the vehicle kept overnight *

Is the vehicle kept at the same address *

If No, what is the full address of where the vehicle is kept

Registered Keeper

Legal Owner

Have you or any of the drivers ever had insurance declined, cancelled or special terms imposed?

Yes
No

Use of vehicle *

Estimated Annual Mileage

Type of Cover

Any no claims discount *

Was this NCD earned in the UK

Would you like to protect your NCD

What voluntary excess would you like *

How do you normally pay for insurance *

When would you like the policy to start *

Additional Drivers

Would you like to add an additional driver

Yes
No

Additional Driver (1) Details

Title *

First Name *

Surname *

Relationship to Proposer/Policy Holder *

Date of Birth *

Marital Status *

Employment Status *

If Employed/Self Employed, what is your occupation:

If Employed/Self Employed, what type of business:

Type of licence *

Period License held for *

If less than 3 years, what date was licence obtained

DVLA medical conditions or disabilities *

Were you born in the UK

If No, when did you last become a UK resident

Use of any other vehicles *

Non motoring criminal convictions

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years

Yes
No

Motor Accidents or Claim Details

1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

2

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

3

Type

Date

Damage

Cost(£) - if known:

Fault

Any Injuries

Yes
No

4

Type

Date

Damage

Cost(£) - if known:

Fault

Any Injuries

Yes
No

Any motor convictions, fixed penalties or disqualifications in the last 5 years

Yes
No

Motor Accidents or Claim Details

1

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

2

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

3

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

4

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

Would you like to add another additional driver (2)

Yes
No

Additional Driver (2) Details

Title *

First Name *

Surname *

Relationship to Proposer/Policy Holder *

Date of Birth *

Marital Status *

Employment Status *

If Employed/Self Employed, what is your occupation

If Employed/Self Employed, what type of business

Type of licence *

Period License held for *

If less than 3 years, what date was licence obtained

DVLA medical conditions or disabilities *

Were you born in the UK

If No, when did you last become a UK resident

Use of any other vehicles *

Non motoring criminal convictions

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years

Yes
No

Motor Accidents or Claim Details

1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

2

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

3

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

4

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Yes
No

Any motor convictions, fixed penalties or disqualifications in the last 5 years

Yes
No

Motor Conviction, Fixed Penalty or Disqualification Details

1

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

1

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban(months) - if any

1

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Points

Fine(£) - if any

Ban(months) - if any

Additional comments

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