Commercial Vehicle Quotation Form

Please fill out the form below in as much detail as possible. Fields marked with a YELLOW asterisk are mandatory - and will enable us to complete a valid quote for you.
Client / Company Details
* Policy Proposer *
Type Of Trade

A to E

F to O

P to Z

If "Miscelleneous" please give details
Title
Fore Names
Surname
Company Name
Full Address
* Post Code *
Home Telephone
Home Fax Number
Work Telephone
Work Fax Number
Mobile Telephone
* E-mail Address *
* Inception Date or Renewal Date *
 
Vehicle Details
* Vehicle Type * eg. Van
* Make * eg. Ford
* "Exact" Model * eg. Transit 190 LWB Hi-roof
* Vehicle Registration * M123 ABC
* Date 1st registered * dd/mm/yyyy
* Cubic Capacity * c.c.
* Fuel Type *
Carrying Capacity Tons
Gross Vehicle Weight Tons
* Q Registration ? *
* Transmission Type *
* Vehicle Colour *
* Paint Finish *
* Date Purchased *
* Purchase Price £ *
* Present value £ *
* Number of seats *
* Which Side is the Steering Wheel
 *
* Current Speedometer Reading *
Estimated Annual Business Mileage
Estimated Annual Private Mileage
Vehicle Security

* Type of immobiliser

*
If Approved-->

Exact model if possible.

Manufacturer: Model: Thatcham Catagory I OR II

* Type of alarm

*
If Approved-->

Exact model if possible.

Manufacturer: Model: Thatcham Catagory I OR II

* Type of tracker

*
If Approved-->

Exact model if possible.

Manufacturer: Model: Thatcham Catagory I OR II
* Where Vehicle Manufactured *
Trailer / Container Cover Required ? *
Trailer Details
Number To Be Insured
Detached Cover
Value Of Unit/s List Individually.
Gross Weight of Each Unit tons
Container Details
Number To Be Insured
Detached Cover
Value Of Unit/s List Individually.
Gross Weight of Each Unit tons
* Licence /Use *
* Toxic / Hazardous Goods *
* 'Airside' Use *

* Vehicle
Modifications ?

 *
If yes, give details
   
* Where kept at night *
Post Code if different from Home Address
Cover Details
* Who Will Drive *
* Cover Details *
* Voluntary Excess *
* No Claims Bonus *
* Protected Bonuses ? *
Proposer's Details
* Date Of Birth *
Title
Fore Names
Surname
Sex
Marital status
Residency in UK years
Country of origin Please specify ie (UK)
* Driving licence type *
* Date Test Passed * dd/mm/yyyy
* Main Driver ? *
* Any Refusals ? *
If YES, please give details
Do You Own Any Other Vehicle ?
 - if Yes NCB May reduce premium
*Home Owner ? *
Occupation (Job Title)
Employment Type
Any Further Drivers ?
*
 
Additional Driver One Details
Date Of Birth
Title
Fore Names
Surname
Sex
Marital status
Relationship To Proposer
Residency in UK years
Country of origin Please specify ie (UK)
Driving licence type
Date Test Passed dd/mm/yyyy
Main Driver ?
Any Refusals ?
If YES, please give details
Do They Own A Vehicle ?
 - if Yes NCB May reduce premium
*Home Owner ? *
Occupation (Job Title)
Employment Type
Any Further Drivers ?
 
Additional Driver Two Details
Date Of Birth
Title
Fore Names
Surname
Sex
Marital status
Relationship To Proposer
Residency in UK years
Country of origin Please specify ie (UK)
* Driving licence type *
Date Test Passed dd/mm/yyyy
Main Driver ?
Any Refusals ?
If YES, please give details
Do They Own A Vehicle ?
 - if Yes NCB May reduce premium
*Home Owner ? *
Occupation (Job Title)
Employment Type
Any Further Drivers ?
 
Additional Driver Three Details
Date Of Birth
Title
Fore Names
Surname
Sex
Marital status
Relationship To Proposer
Residency in UK years
Country of origin Please specify ie (UK)
* Driving licence type *
Date Test Passed dd/mm/yyyy
Main Driver ?
Any Refusals ?
If YES, please give details
Do They Own A Vehicle ?
 - if Yes NCB May reduce premium
*Home Owner ? *
Occupation (Job Title)
Employment Type
Any Further Drivers ?
 
Additional Driver Four Details
Date Of Birth
Title
Fore Names
Surname
Sex
Marital status
Relationship To Proposer
Residency in UK years
Country of origin Please specify ie (UK)
* Driving licence type *
Date Test Passed dd/mm/yyyy
Main Driver ?
Any Refusals ?
If YES, please give details
Do They Own A Vehicle ?
 - if Yes NCB May reduce premium
*Home Owner ? *
Occupation (Job Title)
Employment Type
 
Driver Claims
* Any Claims In Last 5 years
 * Whether at fault or not
   
Claim 1
Which Driver
Incident Type
Date Of Claim dd/mm/yyyy
Amount Claimed £
Claim 2
Which Driver
Incident Type
Date Of Claim dd/mm/yyyy
Amount Claimed £
Claim 3
Which Driver
Incident Type
Date Of Claim dd/mm/yyyy
Amount Claimed £
Claim 4
Which Driver
Incident Type
Date Of Claim dd/mm/yyyy
Amount Claimed £
Claim 5
Which Driver
Incident Type
Date Of Claim dd/mm/yyyy
Amount Claimed £
 
Driver Convictions
* Any Convictions In Last 5 years
 * Whether at fault or not
Conviction 1
Which Driver
Conviction code Codes - Axx to Lxx
  Codes - Mxx to Xxx
Conviction date dd/mm/yyyy
Fine Imposed £
Points
Disqualified period months
If DRxx - Sample level milligrams
Conviction 2
Which Driver
Conviction code Codes - Axx to Lxx
  Codes - Mxx to Xxx
Conviction date dd/mm/yyyy
Fine Imposed £
Points
Disqualified period months
If DRxx - Sample level milligrams
Conviction 3
Which Driver
Conviction code Codes - Axx to Lxx
  Codes - Mxx to Xxx
Conviction date dd/mm/yyyy
Fine Imposed £
Points
Disqualified period months
If DRxx - Sample level milligrams
Conviction 4
Which Driver
Conviction code Codes - Axx to Lxx
  Codes - Mxx to Xxx
Conviction date dd/mm/yyyy
Fine Imposed £
Points
Disqualified period months
If DRxx - Sample level milligrams
Conviction 5
Which Driver
Conviction code Codes - Axx to Lxx
  Codes - Mxx to Xxx
Conviction date dd/mm/yyyy
Fine Imposed £
Points
Disqualified period months
If DRxx - Sample level milligrams
 
Driver Infirmities
* Any Inirmities
 *
Infirmity 1
Which Driver
Type of Infirmity
Has DVLC Been Notified
Date Infirmity Confirmed dd/mm/yyyy
Infirmity 2
Which Driver
Type of Infirmity
Has DVLC Been Notified
Date Infirmity Confirmed dd/mm/yyyy
Infirmity 3
Which Driver
Type of Infirmity
Has DVLC Been Notified
Date Infirmity Confirmed dd/mm/yyyy
Infirmity 4
Which Driver
Type of Infirmity
Has DVLC Been Notified
Date Infirmity Confirmed dd/mm/yyyy
Infirmity 5
Which Driver
Type of Infirmity
Has DVLC Been Notified
Date Infirmity Confirmed dd/mm/yyyy
In accordance with ABI regulations the quote will be sent to you by post with
a prospectus and proposal form.