fields marked with * are required
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Proposer Details |
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Proposer Name * |
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Telephone * |
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Fax * |
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Email * |
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Contact Address & Post Code * |
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Nature of Business |
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Type of goods to be carried in vehicle/s |
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Overnight Parking Post Code |
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Nos of Years Trading |
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Nos of Years Experience in Trade |
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Policy Details |
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Date of Cover required from |
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Current Insurer |
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Type of Cover |
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Nos of Years No claims discount |
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No Claims discount Protection |
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Yes
No
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Current Premium £ |
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Current Policy Excess £ |
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Drivers |
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Drivers |
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(only if applicable) |
Main Driver’s Name |
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DOB |
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Type of Licence |
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Test Passed Date |
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Occupation |
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Date of UK Residence |
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Class of Use Required
(SDP is automatically included)
Commuting to & from Work, Own Goods, In connection with Employers Business, Haulage, Hire & Reward (private/public), self drive Hire, Stage Fare, Other |
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Other Drivers
(Provide same details as for main driver)) |
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Convictions & Claims |
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Do you have any Convictions (incl pending)
in the last five years |
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Yes
No
( if YES - give details )
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Have any claims been made in
the past five years |
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Yes
No
( if YES - give details )
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Prime Vehicle Details |
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Make / Model * |
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Reg Number |
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Value |
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Year of Make |
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Engine size / cc * |
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Gross Vehicle Weight
(In Tons) |
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Any Modifications
(ie Refrigerated or attachments ie cranes) |
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Any Security Device fitted |
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Yes
No
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Cover for more Vehicles required |
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Yes
No
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Additional Information Required for Fleet Quotations |
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Please state total number of vehicles in fleet and whether the combined value of the vehicles exceeds £250,000 |
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Total number of vechiles. Yes
No
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Advise details of any hazardous goods ie of an explosive, corrosive or dangerous nature are carried in the vehicles |
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Main Driver name * Please give details of ‘risk management systems’ in place – ie drivers being personally responsible of policy excess etc |
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It will be assumed that ALL drivers licences are checked at Inception of Employment and rechecked on an Annual basis. |
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For convenience please email or fax or post us a copy of schedule showing vehicle/cover details. Alternatively you can go through information by speaking to one of advisers during opening hours Mon-Fri 9.30 to 5.30 (Weds close – 4.30pm) |
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