Motor Accidents

Have you had any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years

Yes No

Motor Convictions

Have you had any motor convictions, fixed penalties or disqualifications in the last 5 years

Yes No

Vehicle Details

Vehicle Registration

Manufacturer:

Model

Alarms - Immobiliser:

Factory Fitted Thatcham Approved Alarm/Immobiliser Factory Fitted Thatcham Approved Alarm Factory Fitted Non-Thatcham Alarm/Immobiliser Factory Fitted Non-Thatcham Alarm Factory Fitted None

Do you have a dashcam fitted in your van?

Yes No

Number of doors:

Engine Size (CC):

Transmission:

Manual Automatic

Fuel Type:

Petrol Diesel Electric LP Gas

Body Type:

Roof Type:

Normal Roof High Roof

Wheel Base:

Long Wheel Base Medium Wheel Base Short Wheel Base

Does the vehicle have any modifications?

Yes No

Vehicle Usage

Date of purchase

What is the current value of the van?

Where is the vehicle kept during the day:

At Home Office or Factory Car Park Open public car park Secure public car park Street away from home

Where is the vehicle kept overnight:

Garaged Public Road Drive Private Property Car Park Locked Compound

Is the vehicle kept at the same address:

Yes No

If No, what is the full address of where the vehicle is kept:

Carriage of dangerous goods:

Yes No

Who is the car registered to?

Proposer Company Leased Private Leased Company Society or Club Other

Who is the owner of the car?

Proposer Company Other

Any driver insurance declined, cancelled, voided or special terms imposed

Yes No

Use of Vehicle

Social, domestic and pleasure only (SDP) Social, domestic, pleasure, commuting (SDPC) Business use (Carriage Of Own Goods) Haulage use (delivering goods for Hire & Reward)

Estimated Annual Mileage:

Type of Business:

Sole Trader Limited Company Partnership Other

Type of Cover

Comprehensive Third party fire & theft Third party only

Any no claims discount

How did you earn your no claims discount:

With this vehicle or a previous vehicle With a company vehicle In another country

Was this NCD earned in the UK:

Yes No

Would you like to protect your NCD

Yes No

Do you have any other NCD on your private car (if applicable):

What voluntary excess would you like:

How do you normally pay for insurance:

Monthly Annually

When would you like the policy to start

Additional Drivers

Would you like to add an additional driver

Yes No

Additional Comments