Chelmsford Insurance Centre Corporate Services Ltd

Showmans Commercial Vehicle Insurance - Quote Request Form

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.

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
Employers Business
Period of insurance from	Time (24 hrs)
	Date (DD/MM/YY)
Annual Mileage
VAT Registered?	Yes No
Is the Vehicle kept in a locked garage over night at the address shown?	Yes No
Homeowner	Yes No

VEHICLE DETAILS

Make & Model
Engine Size
Max. Carrying Capacity
Gross Vehicle Weight (GVW)
Year of Manufacture
Left or Right Hand Drive
Date of Purchase
Number of Seats
Registration Number
Type of Body
Transmission/Fuel
Main Colour
Present Value
Price Paid
Maximum Mileage for Period of Insurance	Private
	Business
Is the vehicle imported?	Yes No
Mileometer Reading

COVER AND USE

Cover	Comprehensive Third Party Fire & Theft
Please indicate the Class of Use required	Social Domestic & Pleasure Only Carriage of Own Goods Haulage
Will you carry fare paying passengers?	Yes No
Will the vehicle be used for mobile catering?	Yes No
Will the vehicle be used on or at airfields?	Yes No
Are goods to be carried?	Yes No
Will the vehicle be used for carriage of livestock?	Yes No
Will any corrosive, explosive, inflammable, toxic hazardous or dangerous goods be carried?	Yes No
Will the vehicle have trailers attached?	Yes No
Will the vehicle have any containers attached?	Yes No
(Cover for trailers/containers is limited to third party whilst attached)
If Yes, please specify in full?

OWNERSHIP

Do you own the vehicle?	Yes No
If No, please give details here?
Do you or any other member of your household own or insure any other vehicle?	Yes No
If Yes, please give details here?
Date of purchase of vehicle

DRIVERS

Who is the main user of the above vehicle?
Who will drive?	Yourself Only Yourself and Wife/Husband only Yourself and up to three Named Persons
Give full details below in respect of YOURSELF and ALL others who drive.
Full name	All occupations (including part time)	Employers Business	Date of Birth	Type of driving licence held	How long has the licence been held?





Will any person (other than yourself) drive the vehicle?	(a) be under 25 years of age? Yes No (b) hold a provisional licence? Yes No (c) have had less than one year's driving experience? Yes No
If 'YES' full details must be shown.
Are you a smoker?	Yes No

Previous Experience

Have you or any person who may drive:-
(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. If 'YES' to disabilities have you advised DVLA?

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: 13-jun-08

Chelmsford Insurance Centre Corporate Services Ltd are regulated by the Financial Services Authority registration number 301037

Registered in England and Wales No: 4002469. Registered Office: 47 Church Street, Great Baddow, Chelmsford, Essex. CM2 7JA.
Copyright © Chelmsford Insurance Centre Corporate Services Ltd. All rights reserved.	Legal Notices \| SiteMap