CLASSIC CAR QUOTE FORM

Your Email:

Name of proposer:

Date of birth:

Marital status:

Occupation:

Telephone Number:

Home address:

Will the vehicle be garaged?

Yes No

Full make and model of vehicle to be insured:

Year of manufacture?

Engine size?

Value?

Registration Number?

Annual Mileage?

Has the vehicle been modified?

Yes No

If yes, please provide full details:

Is the vehicle to be used for pleasure Purposes only?

Yes No

If not, please provide details:

Do you wish to include additional Drivers?

Yes No

If yes, please provide names, occupation and date of birth:

Has any driver been convicted of any motoring offences?

Yes No

If yes, please provide full details:

Has any driver made a claim in the last 5 years?

Yes No

If yes, please provide full details:

Does any driver suffer from any Medical conditions?

Yes No

If yes, please provide full details:

How many vehicles are in your household?

Can you comply with the following Material Facts statement?

Not been declared bankrupt/insolvent:

Yes No

Not been the subject of bankruptcy proceedings:

Yes No

Not had a proposal refused or declined:

Yes No

Not had a renewal refused:

Yes No

Not had insurance cancelled:

Yes No

Not had special terms imposed:

Yes No

Has no non-motoring convictions or criminal offences:

Yes No

Has no non-motor prosecutions pending:

Yes No

Renewal Date:

Current Insurer:

Target Premium: