Full name:
Date of Birth:
Address:
Postcode:
Company Registration Number:
Number of years established:
Full Nature of Business or Trade:
Principals/Partners/Subsidiary Companies:
Period of Cover
From:
To:
General Questions
1. Have you ever traded under a different name?
Yes
No
If Yes please give details and reasons for change:
2. Do you hold a Goods Vehicle Operators Licence?
Yes
No
If Yes, Type of Licence held, Licence No. Date of expiry:
3 Have you or any director or partner ever been:
i) Convicted of or charged (but not yet tried) with any criminal offence other than motor?
Yes
No
ii) Declared bankrupt or insolvent?
Yes
No
iii) A director or partner of a company that went into liquidation?
Yes
No
iv) The subject of a recovery action by Customs and Excise or the Inland Revenue?
Yes
No
If 'Yes' to any part of Question 3, full details must be given
Driver Details
Provide details of all drivers who to your knowledge will drive the vehicle. Drivers under 25 years of age who may use the vehicle must be included below, as the policy will be issued excluding drivers under 25 if none are shown
Driver Name:
Date of Birth:
Occupation :
Does driver hold a full licence?
Yes
No
Dates first obtained?
Have you or any person who to your knowledge will drive the vehicle
1. been involved in any accidents or losses regardless of blame during the past fiive years in connection with any mechanically propelled vehicle?
Yes
No
If Yes, please give details
Driver's Name:
Date of Accident
Own damage
Third Party Cost
Circumstances?
2. received a fixed penalty notice, been convicted or have a prosecution pending for any motoring offence?
Yes
No
If Yes, please give details:
Drivers Name
Date of Conviction
Conviction Code
Fine
Penalty Points
Suspension
Circumstances?
3. have defective eyesight or hearing, or any other physical or mental defect or disease or suffered from any heart complaint, epilepsy or diabetes?
Yes
No
4. been required by another insurer to pay an increased premium OR bear special terms or conditions?
Yes
No
5. had a policy cancelled OR a proposal declined OR renewal refused by an insurer?
Yes
No
If Yes to questions 3, 4 or 5, please give details and state question answered
6. Have you or any of your drivers passed the RoSPA Advanced Drivers Test?
Yes
No
If Yes, please give details
Penalty Points
Suspension
Circumstances?
Vehicle Details
Vehicle 1
Vehicle 2
Vehicle 3
Registration Mark:
Year of Make:
Make, Model:
Seating Capacity:
Type of body:
Gross vehicle weight:
Plated weight:
Date of purchase:
Price paid by Proposer:
Estimated present value:
Is vehicle right hand drive?
Yes
No
Yes
No
Yes
No
1. Has any vehicle a variation of chassis or body from manufacturer's standard specification?
Yes
No
2. Is any vehicle owned or registered by a person OTHER THAN YOURSELF?
Yes
No
If Yes to question 1 or 2, please give full details:
Use Details
1. Is any vehicle used for the carriage of goods for hire or reward?
Yes
No
2. Is any vehicle used on or at airports or airfields?
Yes
No
3.
a) What is the nature of the goods carried?
b) Will any corrosive, explosive, inflammable, toxic or otherwise dangerous goods be carried? ?
Yes
No
If Yes, please give details
Note Goods in transit are not covered by the insurancebut a separate policy can be arranged.
4. In what circumstances will passengers be carried?
Yes
No
Garaging and Security
Vehicle 1
Vehicle 2
Vehicle 3
(Please state the Postcode where the vehicle is kept overnight)
Is the vehicle
a) kept overnight in a locked garage or a secure locked compound?
b) kept overnight in a private driveway?
c) left overnight in the street?
Is your vehicle fitted with any anti-theft devices?
Yes
No
If Yes, please give details:
Cover Requirements
Drivers Required
Vehicle 1
Vehicle 2
Vehicle 3
One named driver only:
Two named drivers only:
Any authorised driver:
Cover Required
Vehicle 1
Vehicle 2
Vehicle 3
Comprehensive without voluntary damage excess:
Comprehensive with voluntary damage excess:
(if required insert 50/75/100/250)
Third Party Fire and Theft:
Third Party:
Number
Max Value £
Total Value £
Trailers and Containers:
No Claims Discount
Name your previous insurers in respect of any mechanically propelled vehicle.
If no previous insurance, state how driving experience was gained.
Vehicle 1
Vehicle 2
Vehicle 3
State number of years No Claim Discount entitlement and attach insurer's renewal notice.