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Specialist Vehicle Quotation

Name

Postcode

Email address

Daytime contact number

Vehicle Type

Vehicle registration (if known)

Purchase Date

Vehicle make

Vehicle model

Engine make

Engine size cc

BHP

Cover required

Annual mileage limit

Value £

Where is the vehicle kept overnight

Age of vehicle

What security is fitted to the vehicle

Are you a member of a relevant Car Club

Will this be your main or only vehicle

Are you the main user

How many drivers to be on the policy

Class of Use (SD&P = Social Domestic & Pleasure)

Driver 1 Name

Date of Birth

Marital Status

Occupation

Nature of Business

Date passed full UK driving licence

Is the number of claim-free years on this vehicle or another vehicle

Number of years claim free driving

Please give details of any accidents, thefts, losses or other claims in the last five years

Please give details of any motoring convictions received in the last five years

Driver 2 Name

Date of Birth

Postcode

Occupation

Nature of Business

Date passed full UK driving licence

Number of years claim free driving

Please give details of any accidents, thefts, losses or claims in the last five years

Please give details of any motoring convictions received in the last five years

Driver 3 Name

Date of Birth

Postcode

Occupation

Nature of Business

Date passed full UK driving licence

Number of years claim free driving

Please give details of any accidents, thefts, losses or claims in the last five years

Please give details of any motoring convictions received in the last five years

Driver 4 Name

Date of Birth

Postcode

Occupation

Nature of Business

Date passed full UK driving licence

Number of years claim free driving

Has any driver ever been disqualified from driving, refused insurance or quoted increased premium or had special terms inposed

Have all drivers been UK resident for 3 or more years?

Please give details of any accidents, thefts, losses or claims in the last five years

Please give details of any motoring convictions received in the last five years

Has any driver ever suffered/currently suffer from any physical/mental infirmity heart/diabetic/epileptic or other medical condition, defective vision/hearing not corrected by optical or hearing aids, or regularly take any prescribed medication

if you have answered yes to the last two questions please give details here

Renewal date of current insurance

Current renewal premium/quotation

Would you like a quotation for optional Breakdown cover?

Would you like a quotation for optional Legal Expenses cover?