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 are mandatory), and then press the Submit button.

YOUR CONTACT DETAILS
Title*		Mr Mrs Ms Dr Other
First Name*
Surname*
Address
City/Town
County
Postcode
Country
Telephone No.*
Fax No.
Mobile No.
Email Address*
Best time to contact you		As soon as possible Morning Afternoon Evening
VEHICLE DETAILS
Vehicle Type		Up To 3.5 Ton Over 3.5 Ton Minibus
Number of vehicles to insure		One To Five Vehicles More Than Five Vehicles
Have there been any modifications to the vehicle?		Yes No
Details of any modifications made?
Vehicle Use		Business Use Social Domestic Use Both
Make and model of vehicle
Vehicle registration number
Engine size
Year of manufacture
Value of vehicle (£)
Non standard vehicle alarm fitted		Yes No
Immobiliser		Yes No
Tracking device		Yes No
Where is vehicle stored overnight?		Garage Private Driveway Public Road
Overnight storage postcode
Approximate annual mileage
INSURANCE DETAILS
When would you like your new policy to start? dd/mm/yyyy
Is this a new policy or a renewal?		New policy Renewal
What is your current premium (£)
Who is your current insurer
Have you ever made any claims?		Yes No
DRIVER DETAILS
		Name	Date of Birth	Occupation	Years with full license	Convictions on licence
Main driver						Yes No
Additional A						Yes No
Additional B						Yes No
Additional C						Yes No
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 on a car or van? 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?
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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