Renewal Date of Existing Insurance
Name of proposer
Address
Phone No. (H)
Phone No. (W)
Business Address
Email
Date of Birth
Age
Martial Status
Occupation
Type of Licence held Full
How long is licence held?
Any accidents, claims, convictions? Yes
If so, please fill in the following:
Date
Circumstances
Cost of claim
DETAILS OF OTHER DRIVERS
(1)
Name
Relationship to proposer
Date of Birth
Age
Occupation
Type of licence Full
How long is licence held
Any accidents, claims or convictions Yes
If so, please fill in the following:
Date
Circumstances
Cost of claim
(2)
Name
Relationship to proposal
Date of Birth
Age
Occupation
Type of licence Full
How long is licence held
Any accidents, claims or convictions Yes
If so, please fill in the following:
Date
Circumstances
Cost of claim
(3)
Name
Relationship to proposar
Date of Birth
Age
Occupation
Type of licence Full
How long is licence held
Any accidents, claims or convictions Yes
If so, please fill in the following:
Date
Circumstances
Cost of claim
DETAILS OF VEHICLE
Make
Model
Petrol or Diesel
Year of Make
Type of Body ie. Car/Van
Cubic Capacity
Value
Do you or your spouse have full-time use of any
other motor vehicle Yes
If so, please give details:
Make
Model
Cubic capacity
No claims bonus
Do any drivers hav any physical defects or
infirmities? Yes
If so, please give details
Are all the drivers non drinkers? Yes
Are you a smoker? Yes
Are you a homeowner? Yes
How many years no claim bonus have you?
How many years have you been insured as a named
driver?
Name of present insurers?
Present Premium
What is the most competitive quote you have?
From whom?
What type of cover do you require:
Third Party, Third Party Fire and Theft or
Comprehensive?
Please Choose
Third Party
Third
Party Fire and Theft
Comprehensive
What is your estimated annual mileage?
Is vehicle used for private or business
purposes?
Date of application for quotation
