COMMERCIAL VEHICLE QUOTE FORM

Your Email:

Company Name:

Occupation/Trade:

Telephone Number:

Correspondence address:

Full make and model of vehicle to be insured :

Year of manufacture:

Engine size:

Value:

Registration Number:

Annual Mileage:

Will the vehicle be kept at the business Address at night?

Yes No

If not, please provide full details:

Has the vehicle been modified?

Yes No

If yes, please provide full details:

Is the vehicle to be used for pleasure and the carriage of own goods?

Yes No

If no, please provide details:

Do you wish to include more than one driver?

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 years no claims discount do you have?

Do you wish to include protected no claims discount?

Yes No

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: