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info@easyaffordinsurance.co.uk

Car/Bike Insurance Form

Step 1

Personal Info

How did you hear about us?
Your preferred title

About You

First Name
Last Name
Date of Birth
Marital Status
Have you been a UK resident since birth?
If not UK resident then in which country you are national:
Address
Post Code
Town or City
Employment Status
Home Owner

Contact Details

Email
Phone Number
WhatsApp Number

Driving History

Licence Type
Period Licence Held For
Licence Obtained Date
Insurance declined/cancelled?
Specific companies to avoid?
Current Insurance Provider
How much you are paying for current insurance?
Non-motoring criminal convictions?

Motor Accidents (5 Years)

Motor Convictions (5 Years)

Which level of cover do you need?
How will this car be used?
When should cover start for this car?
How do you prefer to pay for your insurance?

Personal Details

Gender
Primary Residence
Moved in Last 2 Months?

Vehicle Details

Vehicle Registration
Date of purchase
Current Value
Registered to
Owner of vehicle
Annual Mileage
Use of Vehicle

Where is this car kept overnight?

What address will the car be kept at overnight?
Where will this car be kept overnight?
How much excess are you willing to pay?
No Claims Discount (NCD)
Policy Start Date
Payment Method Preference

Additional Drivers

Preferred title?
First Name:
Last Name:
Driver's Date of Birth
Has the driver lived in the UK continuously since birth?