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Private Car Quotation
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Proposer
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Address
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E-mail
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Occupation
*
Type of UK licence held
*
Please select
Full
Provisional
Other
Please specify type of licence
*
How long licence held for
*
Please select
10+ years
9 years
8 years
7 years
6 years
5 years
4 years
3 years
2 years
1 year
11 months
10 months
9 months
8 months
7 months
6 months
5 months
4 months
3 months
2 months
1 month
3 weeks
2 weeks
1 week
Less than 1 week
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 if 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
Please give full details of all motoring convictions
*
Conviction Code
Date
Points
Ban (length in months)
Conviction 1
Conviction 2
Conviction 3
Conviction 4
Have you had any NON MOTORING convictions
*
No
Yes
Enter 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
*
Please select
9+ years
8 years
7 years
6 years
5 years
4 years
3 years
2 years
1 year
Nil
Do you require Protected No Claims Bonus
*
No
Yes
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Vehicle Details
Registration number
*
Make
*
Model
*
Derivative
*
Body type
*
Please select
Hatchback
Saloon
Coupe
Convertible/ Cabriolet
Estate/ Station Wagon
Pick Up
Van
Caravanette
Fuel Type
*
Petrol
Diesel
Electric
LPG
Transmission
*
Manual
Automatic
Engine size (cc)
*
Value (£)
*
Where is vehicle kept when not in use
*
On driveway
Garage
Road
Car Port
Car Park
Other
Registered owner of the vehicle
*
Proposer
Other
Is the vehicle Right Hand Drive
*
Yes
No
Has the vehicle been modified
*
No
Yes
Modifications
*
Date vehicle purchased
*
-
Day
-
Month
Year
Date
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Cover Details
Cover required
*
Comprehensive
Third Party Fire & Theft
Third Party Only
Use
*
Please select
Social, Domestic & Pleasure Only(SD&P)
SD&P inc. Commuting to and from one permanent place of work
SD&P inc. Personal business use by policyholder
SD&P inc. Personal business use by spouse
SD&P inc. Personal Business use by policyholder & spouse
Annual social use mileage
*
Please select
1500 miles
3000 miles
5000 miles
7500 miles
12000 miles
15000 miles
20000 miles
Annual business use mileage
*
Please select
1500 miles
3000 miles
5000 miles
7500 miles
12000 miles
15000 miles
20000 miles
Driving restrictions
Insured Only Driving
Insured & Spouse to drive
Insured & Named driver('s)
Any driver over 25
Any driver over 30
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Details of Spouse
S1) Full name
*
First Name
Last Name
S2) Date of birth
*
1
2
3
4
5
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Day
January
February
March
April
May
June
July
August
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October
November
December
Month
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
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1999
1998
1997
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
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1984
1983
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1981
1980
1979
1978
1977
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1975
1974
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1972
1971
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1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
S3) Occupation
*
S4) Type of UK licence held
*
Please select
Full
Provisional
Other
S5) How long licence held for
*
Please select
10+ years
9 years
8 years
7 years
6 years
5 years
4 years
3 years
2 years
1 year
11 months
10 months
9 months
8 months
7 months
6 months
5 months
4 months
3 months
2 months
1 month
3 weeks
2 weeks
1 week
Less than 1 week
S6) 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
S7) Please enter details of all claims in the last 5 years
*
Date
Fault or Non Fault
Cost of claim
Description if incident
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5
S8) Have you had any motoring convictions, fixed penalties or licence endorsements within the last 5 years including anything pending?
*
No
Yes
S9) Please give full details of all motoring convictions
*
Conviction Code
Date
Points
Ban (length in months)
Conviction 1
Conviction 2
Conviction 3
Conviction 4
Conviction 5
S10) Have you had any NON MOTORING convictions
*
No
Yes
S11) Enter details of all non motoring convictions
*
S12) Have you ever had a policy voided, refused of cancelled by any insurance company?
*
No
Yes
S13) Please give full details stating why your policy was voided, refused or cancelled by an insurance company
*
S14) Do you require an additional named driver
*
No
Yes
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Named Driver 1
ND1.1) Full name
*
First Name
Last Name
ND1.2) Date of birth
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
ND1.3) Occupation
*
ND1.4) Type of UK licence held
*
Please select
Full
Provisional
Other
ND1.5) How long licence held for
*
Please select
10+ years
9 years
8 years
7 years
6 years
5 years
4 years
3 years
2 years
1 year
11 months
10 months
9 months
8 months
7 months
6 months
5 months
4 months
3 months
2 months
1 month
3 weeks
2 weeks
1 week
Less than 1 week
ND1.6) 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
ND1.7) Please enter details of all claims in the last 5 years
*
Date
Fault or Non Fault
Cost of claim
Description if incident
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5
ND1.8) Have you had any motoring convictions, fixed penalties or licence endorsements within the last 5 years including anything pending?
*
No
Yes
ND1.9) Please provide full details of all motoring convictions
*
Conviction Code
Date
Points
Ban (length in months)
Conviction 1
Conviction 2
Conviction 3
Conviction 4
Conviction 5
ND1.10) Have you had any NON MOTORING convictions
*
No
Yes
ND1.11) Enter details of all non motoring convictions
ND1.12) Have you ever had a policy voided, refused of cancelled by any insurance company?
*
No
Yes
ND1.13) Please give full details stating why your policy was voided, refused or cancelled by an insurance company
ND1.14) Do you require an additional named driver
*
No
Yes
Back
Next
Named Driver 2
ND2.1) Full name
*
First Name
Last Name
ND2.2) Date of birth
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
ND2.3) Occupation
*
ND2.4) Type of UK licence held
*
Please select
Full
Provisional
Other
ND2.5) How long licence held for
*
Please select
10+ years
9 years
8 years
7 years
6 years
5 years
4 years
3 years
2 years
1 year
11 months
10 months
9 months
8 months
7 months
6 months
5 months
4 months
3 months
2 months
1 month
3 weeks
2 weeks
1 week
Less than 1 week
ND2.6) 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
ND2.7) Please enter full details of all claims in the last 5 years
*
Date
Fault or Non Fault
Cost of claim
Description if incident
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5
ND2.8) Have you had any motoring convictions, fixed penalties or licence endorsements within the last 5 years including anything pending?
*
No
Yes
ND2.9) Please give full details of all motoring convictions
*
Conviction Code
Date
Points
Ban (length in months)
Conviction 1
Conviction 2
Conviction 3
Conviction 4
Conviction 5
ND2.10) Have you had any NON MOTORING convictions
*
No
Yes
ND2.11)Enter details of ALL non motoring convictions
*
ND2.12) Have you ever had a policy voided, refused of cancelled by any insurance company?
*
No
Yes
ND2.13) Please give full details stating why your policy was voided, refused or cancelled by an insurance company
*
ND2.14) Do you require an additional named driver
*
No
Yes
Back
Next
Named Driver 3
ND3.1) Full name
*
First Name
Last Name
ND3.2) Date of birth
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
ND3.3) Occupation
*
ND3.4) Type of UK licence held
*
Please select
Full
Provisional
Other
ND3.5) How long licence held for
*
Please select
10+ years
9 years
8 years
7 years
6 years
5 years
4 years
3 years
2 years
1 year
11 months
10 months
9 months
8 months
7 months
6 months
5 months
4 months
3 months
2 months
1 month
3 weeks
2 weeks
1 week
Less than 1 week
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 if 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
ND3.9) Please give full details of all motoring convictions
*
Conviction Code
Date
Points
Ban (length in months)
Conviction 1
Conviction 2
Conviction 3
Conviction 4
Conviction 5
ND3.10) Have you had any NON MOTORING convictions
*
No
Yes
ND3.11)Enter 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
*
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