Private Car Quote >> Equity >> Unions >> Hencilla Canworth

Motor Insurance

Request a quote for Private Car Insurance

Please complete and return this questionnaire so we can apply to our panel of insurers for a quote on your behalf. If you have a query regarding how to answer any of the questions please call us on 020 8686 5050.

After submission of the form it may be necessary for us to contact you for additional information to secure a quotation. The information provided will form the basis of your contract with the insurers so it is important that it is accurate.

If you provide false or inaccurate information, withhold information or fail to inform us of any relevant details the policy issued could be cancelled, declared void or the insurers could refuse to pay a claim.

* Required.

You, Proposer

Name of proposer*

Marital Status*

Full address*

Postcode*

Main Occupation*

Any part-time occupation

Nature of your business*

Employment Status*

Mobile Phone Number*

Email Address*

Your Car or Van (Van should be under 3.5 ton)

Registration*

Make & Model*

CC*

Year of Make*

Doors*

Fuel*

Seats*

Vehicle Keeper*

Vehicle Owner*

Purchase Date*

Value (£)*

Where is the vehicle kept overnight*

Postcode where kept overnight* Overnight postcode*

Right or left hand drive*

Mileage per year*

Cover Requirements*

Drivers

You must provide details of yourself and any other person who may drive your car. You must also disclose the details of any medical conditions or disabilities that must be notified to the DVLA, whether the driving license has been restricted or not we may request a copy of your driving license following a claim.

Name (Proposer)*

Age*

Date of Birth*

Occupation*

Employment Status* Employment*

License Type*

Date Passed Test* Pass Date*

Use Required*
Name (Spouse/Partner)

Age

Date of Birth

Occupation

Employment Status* Employment*

License Type

Date Passed Test Pass Date

Use Required
Name

Age

Date of Birth

Occupation

Employment Status* Employment*

License Type

Date Passed Test Pass Date

Use Required
Name

Age

Date of Birth

Occupation

Employment Status* Employment*

License Type

Date Passed Test Pass Date

Use Required
Name

Age

Date of Birth

Occupation

Employment Status* Employment*

License Type

Date Passed Test Pass Date

Use Required

Convictions

In the last five years, have you or any person who may drive, been convicted of any motor offences (including fixed penalties) been disqualified from driving or are there any prosecutions pending

Yes, I have got convictions within the last five years I have had no conviction(s) within the last five years

PLEASE PROVIDE THE DETAILS BELOW. Any additional information that cannot fit please use the Any additional information about you or the vehicle in the very last box.

Name of driver*

Date of offence*

Date of conviction*

Offence code*

Penalty Points*

Fine (£)*

Disqualified (Months)*
Name of driver

Date of offence

Date of conviction

Offence code

Penalty Points

Fine (£)

Disqualified (Months)
Name of driver

Date of offence

Date of conviction

Offence code

Penalty Points

Fine (£)

Disqualified (Months)

Accidents/Claims/Losses

Have you or any person who may drive had any accidents/claims/losses (whether to blame or not) in connection with ANY motor vehicle during the last five years?

Yes, I have had an Accident/Claims/Losses within the last five years I have had no Accident/Claims/Losses within the last five years

PLEASE PROVIDE THE DETAILS BELOW. Any additional information that cannot fit please use the Any additional information about you or the vehicle in the very last box.

Name of driver*

Date of incident*

Repair Costs (£)*

Any personal Injury claims?*

Fault or Non-fault?*

Brief Details of the incident*
Name of driver

Date of accident

Repair Costs (£)

Any personal Injury claims?

Brief Details of the incident
Name of driver

Date of accident

Repair Costs (£)

Any personal Injury claims?

Brief Details of the incident

Non-motoring Convictions

Has anyone who may drive been convicted or charged (but not tried) of any non-motoring offences IF YES give details below.

Name of driver

Offence date

Offence Type

Sentence Type

Sentence Length

Early Release Date

Insurance History/Renewal

Name of previous insurer

Policy Number

Expiry Date

No Claims Bonus (Years)*

Is bonus protected?*

Renewal Premium Offered Renewal Premium

Additional Details

Any additional information about you or the car - E.G modifications, medical conditions

* Required.