Reich Private Clients - Motor Quotation

Reich Private Clients - Motor Quotation
Date Required *
Telephone Number*
Email Address*
Client Details
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Nature of Business*
Martial Status*
UK Resident *
If yes how many years?
Home Owner*
Licence type*
Country licence issued in*
Licence length*
Vehicle Details
Registration number*
Make of car*
Model*
Body - Hatch/Sal/Est?*
Fuel Type*
Manual or auto*
Year of make*
Engine size*
Number of doors*
Any modifications? Full details required.
Purchase date*
Is car right hand drive?*
Registered keeper*
Main user*
Estimated current value £*
Business use required?*
Annual mileage*
Alarm/Immobiliser*
No claims discount- Years*
Protected bonus*
Number of cars in h/hold*
Postcode where kept*
Where is car parked during the day? (E.g. road, driveway)*
Where is car kept overnight? (E.g. road, driveway)*
Driver Details

Please complete the following questions:*

	Driver Name	DOB	Sex	Years Resident in UK	Occupation	Nature of Business	Type of Licence	Length Held	Relationship to Proposer	Use Required (Personal or Business use?)
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2
3
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5
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Personal History
Do you or any driver have any accident, losses or claims regardless of blame in the last 5 years?*

If yes, provide details below:

	Name	Date of Accident/Loss	Circumstances	Cost £	Settled Fault or Non-Fault	Personal Injury
1
2
3
4
5

Do you or any drivers have any motoring convictions, cautions or fixed penalties in the last 5 years? You should also note any pending prosecutions/police enquires *

If yes, provide details below:

	Name	Date of Conviction	Offence Code	Points	Fine	Sentence
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2
3
4
5

Do you or any driver have a disability which is notifiable to the DVLA? *

If yes, provide details below:

	Name	Disability	Medication	DVLA Aware? (Y/N)
1
2
3
4

Do you or any driver have any criminal convictions or prosecutions pending?*
If yes, provide details
Have you or any driver even been declared bankrupt or have any Count Court Judgements issued against them?*
If yes, provide details
Have you even been required by any other insurers to pay an increased premium or have any special terms and conditions imposed on a policy?*
If yes, provide details
Have you or any driver had an insurance policy cancelled or insurance refused?*
If yes, provide details
Please upload any relevant documents (licence, insurance schedule etc). Document upload 1:

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Document upload 2:

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Document upload 3:

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Current Provider Details
Current Insurer*
Current Premium*
Current Excess*
How do you wish to pay for your insurance premium?*
Additional Information
How did you hear about Reich?*
General Data Protection Regulation (GDPR)

In order to comply with the General Data Protection Regulation and UK Data Protection legislation, we need to obtain your consent in the following areas: -
Consent to process data? (Required in order to provide quote)*

YesNo
Allowed methods of contact?*

PostPhoneE-mail
Preferred contact method?*

PostPhoneE-mail
Happy to receive information about other products that may be of interest?*

YesNo
Many thanks for your quotation request. Once this form has been successfully uploaded, you will see a "Thank You" page, confirming this has been received by Reich. A member of our team will report back by close of business on the next working day.
Reich Private Clients is a Trading style of Reich Insurance Brokers Ltd FRN: 300416 who are authorised and regulated by the Financial Conduct Authority.
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Reich Private Clients - Motor Quotation

Client Details

Vehicle Details

Driver Details

Personal History

Current Provider Details

General Data Protection Regulation (GDPR)

Many thanks for your quotation request. Once this form has been successfully uploaded, you will see a "Thank You" page, confirming this has been received by Reich. A member of our team will report back by close of business on the next working day.