Motor
Fleet Insurance - Quotation Request
Proposer's Name
E-mail address (required)
Trading as
Address
Postcode
Telephone No
Fax No (optional)
Contact Name (if different from Proposer)
General
Particulars
1) Have you the Proposer or any Partner or Director
ever been convicted of or charged (but not yet tried) with a criminal
offence?
or been declared Bankrupt or Insolvent?
2) Have you the Proposer or any Partner or Director
for the business now being propsed or for any previous business
ever been insured for any of the risks now being proposed?
if you have answered 'yes' to question 2 above yes please give
details below of the name(s), trading name(s) and insurer(s)
Name(s) and trading name(s)
Insurer(s)
Vehicles
to be insured
Click 'move on' at any time that you have completed a section
Vehicle 1
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 2 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 3 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 4 or move
on to
drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 5 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 6 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 7 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 8 or move
on to
drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 9 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Vehicle 10 or move
on to drivers
Make and model/type
Year of manufacture
Cubic capacity
Estimated value (£)
Registration mark
NCD (years) at this renewal
Has the vehicle been modified in any way?
if yes, please give details
Driver
details
To the best of your knowledge will the vehicles be driven by
any person who:
a) has any physical or mental defect or suffers from diabetes,
epilepsy or any heart complaint?
b) has been convicted of any motoring offence (including fixed
penalty offences) during the past 5 years, or has a prosecution
pending, other than for parking?
c) has had a licence suspended during the past 5 years?
d) is under 25 years of age?
if you have answered yes to any of the above driver questions
a-d, please provide details in the additional info box for the
driver(s) involved.
Driver 1
Full name
Date of birth
Date test passed
Additional info
Driver 2 or move
on
Full name
Date of birth
Date test passed
Additional info
Driver 3 or move
on
Full name
Date of birth
Date test passed
Additional info
Driver 4 or move
on
Full name
Date of birth
Date test passed
Additional info
Driver 5 or move
on
Full name
Date of birth
Date test passed
Additional info
Claims
Experience
How long have you been in business?
Has any insurer in respect of any business in which you have
been engaged ever:
a) declined a Proposal, not invited a renewal of a Policy, refused
to renew or cancelled a Policy?
b) imposed special conditions (e.g. premium loading, cover restrictions
or increased excess)?
if you have answered yes to any of the above please
give details
Insurance required from
Renewal date of present insurance
Preferred Payment Method
choose >>>
Credit Card
Debit Card
Cheque
Direct Debit
