American Car / Classic Car Quotation

American Car / Classic Car Quote Form

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How did you hear about us? *
Your Details
Full name *

Prefix First Name Last Name
Date of birth *

Day Month Year

Address *

Street Address
Street Address Line 2
City	County
Post Code	Country

Email *

Confirmation Email
Phone number *
Occupation *
Type of UK licence held *
How long licence held for *
Have you had any accidents or incidents within the last 5 years regardless of blame and whether or not a claim was made *

No Yes

Please enter details of all claims in the last 5 years *

	..........Date..........	.....Fault_or_Non_Fault.....	..........Cost_of_claim..........	....................Description_of_incident....................
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5

Have you had any motoring convictions, fixed penalties or licence endorsements within the last 5 years including anything pending? *

No Yes

Have you had any NON MOTORING convictions *

No Yes
Enter full details of all non motoring convictions *
Have you ever had a policy voided, refused of cancelled by any insurance company? *

No Yes
Please give full details stating why your policy was voided, refused or cancelled by an insurance company *
How many years No Claims Bonus do you hold *
Do you require Protected No Claims Bonus *

No Yes
American Car club member? *

No Yes

Cover Details
Cover required *

Comprehensive Third Party Fire & Theft Third Party Only
Use *
Annual mileage *
Driving restrictions

Insured Only Driving Insured & Spouse to drive Insured & Named driver('s) Any driver over 25 Any driver over 30

Named Driver 3
ND3.1) Full name *

Prefix First Name Last Name
ND3.2) Date of birth *

Day Month Year
ND3.3) Occupation *
ND3.4) Type of UK licence held *
ND3.5) How long licence held for *
ND3.6) Have you had any accidents or incidents within the last 5 years regardless of blame and whether or not a claim was made *

No Yes

ND3.7) Please enter details of all claims in the last 5 years *

	..........Date..........	.....Fault_or_Non_Fault.....	..........Cost_of_claim..........	....................Description_of_incident....................
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5

ND3.8) Have you had any motoring convictions, fixed penalties or licence endorsements within the last 5 years including anything pending? *

No Yes

ND3.10) Have you had any NON MOTORING convictions *

No Yes
ND3.11) Enter full details of all non motoring convictions
ND3.12) Have you ever had a policy voided, refused of cancelled by any insurance company? *

No Yes
ND3.13) Please give full details stating why your policy was voided, refused or cancelled by an insurance company

Are you a robot *
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