Driving School Insurance - Quote Request Form

PROPOSER

Title:*

First Name:*

Surname:*

Address:

City/Town:

County:

Postcode:

Country:

Home Telephone No:*

Work Telephone No:

Fax No:

Mobile No:

Email Address:*

Best time to contact you:

All Occupations

Full Time:

Part Time:

Current ADI grade:

Years of experience:

Current no claims bonus:

Employers Business:

Trading Name:

VAT Registered?

Is the car kept overnight at the address shown?

Is the car kept in:

Vehicle Details

Make of Car:

Exact Model:

Are there any alterations from manufacturers design of body or engine?

Type of Body:

Seating Capacity:

Cubic Capacity:

Year of Make:

Present value of car and accessories:

Registration mark:

In addition to any Manufacturers devices has the vehicle been fitted with an alarm system or an immoboliser or a "tracking" system?

If 'YES' please give details of Make & Model:

Does the car have dual controls?

Cover and Use

Cover:

Comprehensive
Comprehensive with Guaranteed NCD (subject to acceptance)
TPF & T

Will the car be used solely for Social Domestic & Pleasure and driver tuition/training?

If 'NO' please give full details?

Voluntary Excess (comprehensive only) in addition to standard excess:

£100
£150
£250

Ownership

Do you own the car?

Date of purchase of vehicle:

Approximate annual mileage

Drivers: ANY AUTHORISED DRIVER

Give full details below in respect of YOURSELF and ALL other known users of the car.
Please enter at least the first row in this section*

Full name:

All occupations
(including part time)

Employers Business

Date of Birth

Type of licence

Time licence has been held?

Previous Experience:

Have you or any person who may drive (other than a pupil or person under training):

(a) Lost an eye, limb or part of a limb, defective vision or hearing, any physical or mental infirmity, epilepsy, diabetes or any heart or other complaint? Yes No

(b) Any endorsement showing on their driving licence, or been convicted of any motoring offence during the past 5 years, or received a fixed penalty notice or have any prosecution pending? Yes No

(c) Been disqualified from driving or ever had their licence revoked? Yes No

(d) Been refused any motor vehicle insurance or continuation thereof or been required to pay an increased premium or had special conditions imposed by any motor insurer? Yes No

(e) During the last 5 years been involved in any accident, loss or claim irrespective of blame? Yes No

(f) Do you hold or have you ever held motor insurance? Yes No

(g) Are you claiming no claims discount? Yes No

If 'YES' give full details, including dates, circumstances and cost of any claims and convictions?
If 'YES' to disabilities give details. Have DVLA been advised?