Chelmsford Insurance Centre Corporate Services Ltd

Request a quotation from Chelmsford Insurance Services, by filling in as much of the form below as possible (*your name, telephone number and email address, and first driver in the drivers section are mandatory), and then press the Submit button.

PROPOSER
Title*		Mr Mrs Ms Dr Other
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		As soon as possible Morning Afternoon Evening
All Occupations
Full Time
Part Time
Current ADI grade		- 1 2 3 4 5 6 7 8 9 10 (if applicable)
Years of experience		- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 (if applicable)
Current no claims bonus		less than a year 1 2 3 4 5 6 7 8 9 10
Employers Business
Trading Name
VAT Registered?		Yes No
Is the car kept overnight at the address shown?		Yes No
Is the car kept in:		A Garage? A Drive? The Road?
VEHICLE DETAILS
Make of Car
Exact Model		(i.e. Passatt TDI - please be specific here)
Are there any alterations from manufacturers design of body or engine?		Yes No
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?		Yes No
If 'YES' please give details of Make & Model:
Does the car have dual controls?		Yes No
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?		Yes No
If 'NO' please give full details?
Voluntary Excess (comprehensive only) in addition to standard excess		£100 £150 £250
OWNERSHIP
Do you own the car?		Yes No
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 driving licence held	How long has the licence 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?
Please enter the two english words you see with a space between them. If you cannot read it then please just press the refresh button opposite.

Please note: all personal information provided on this form will be used solely for the purposes of answering your query or providing your quote, informing you of future offers and improving our services. This information will NOT be passed to any third party.

Page last updated: 23-feb-09