About You

Full Name

Gender

House/flat number or name

Postcode

Landline Number

Mobile Number

Email address

Confirm your email

How did you hear about us?

How do you normally pay for your insurance?

By selecting next you are agreeing to our Fair Processing Notice

Your Cover

Who will be insured to drive the vehicle?

Number of additional named drivers (EXCLUDING yourself)

What is the age of the youngest driver on the policy?

Cover date

Cover time

Type of cover required

Voluntary excess

Has anyone on the policy ever;

Had any non-motoring convictions?
Been refused insurance in the past?
Had an insurance policy cancelled?
Had an increased premium applied to a policy?
Had terms imposed on a policy?

Does any driver have any non-motoring convictions?

Has anyone on the policy ever been refused insurance in the past?

Has anyone on the policy ever had an insurance policy cancelled?

Has anyone on the policy ever had an increased premium applied to a policy?

Have you ever had terms imposed on a policy?

Have you ever held insurance?

Who was your previous insurer?

How long is it since your previous policy lapsed?

How many years No Claims Bonus have you earned?

Would you like to protect your no claims bonus?

Country in which No Claims Bonus was earned?

On what type of vehicle was this No Claims Bonus earned?

Driver Details -

Full Name

Gender

Date of birth

Marital status

Driving Status

Main occupation

Main business type

Job status

Is this position full or part time?

Do you have a second occupation?

Secondary occupation

Secondary business type

Job status

Is this position full or part time?

How long has this driver lived in the UK?

Licence type

In which country was this licence issued?

How long has this licence been held?

Please advise this person's driving licence number (if possible)

Is this driver a home owner?

What is the typical annual PLEASURE mileage for THIS DRIVER on THIS VEHICLE

Will this driver be using the vehicle for commuting to and from work?

Will this driver be using the vehicle for business purposes?

Does this driver have access to another vehicle or has this driver EVER had access to a Company Car?

Does this driver have any disabilities, illnesses or medical conditions?

Is this medical condition notifiable to the DVLA?

Has the DVLA been advised of the disability?

Has the DVLA issued a licence to drive?

If licence has been restricted please enter the number of years it has been issued

Medical History

Is this driver restricted to only driving automatic vehicles?

Does this driver require modified hand controls?

Does this driver require a wheel knob?

Does this driver suffer from diabetes?

Has this driver got any history of diabetes attacks or coma?

How is the diabetes controlled?

Date diabetes started

Date diabetes became stable

Does this driver suffer from hearing or sight loss?

Date of onset of sight loss

Percentage of loss of sight in left eye

Percentage of loss of sight in right eye

Is the sight problem disease related?

Date of onset of hearing loss

Percentage of loss of hearing in left ear

Percentage of loss of hearing in right ear

Is this driver's hearing problem disease related?

Has this driver lost the use of any limbs?

Date of onset of arm loss

Which arm is affected?

Is the problem with this driver's arm disease related?

Date of onset of leg loss

Which leg is affected?

Is the problem with this driver's leg disease related?

Do you suffer from any other infirmities?

Miscellaneous infirmity 1

Date since onset 1

Date since stable 1

Miscellaneous infirmity 2

Date since onset 2

Date since stable 2

Miscellaneous infirmity 3

Date since onset 3

Date since stable 3

Business Use

What is the typical annual BUSINESS mileage for THIS DRIVER on THIS VEHICLE

Please tell us if this driver will be using this vehicle for the following purposes?

Personal Business Use ?

In connection with his/her employer's business

In connection with someone else's business

for cold calling or sales?

for public hire?

for private hire?

to carry goods?

Driving Record

Accidents/losses in last 3 years whether at fault or not, even if no claim was made?

In the last 5 years has this driver had any motoring convictions, penalty points, been disqualified or is any prosecution pending?

Claims

Other Claims

Convictions

Other Vehicles

Does this driver drive a company vehicle?

Is this driver the only person who drives the company vehicle?

How long has this driver been driving the company vehicle?

Does this driver own a vehicle other than the one being insured by this policy?

The type of the other vehicle this driver owns

Number of years no claims accrued on the other vehicle owned by this driver

Does this driver have access to other vehicles?

Who is the proposer on the insurance policy for this other vehicle?

Number of years no claims bonus earned for the other vehicle?

Vehicle Details

Do you know the registration number of your car?

Registration

Has the vehicle been modified?

Modification 1

Modification 2

Modification 3

Modification 4

Modification 5

Registered Owner?

Registered Keeper?

Purchase date

Vehicle value

Where will the vehicle be parked overnight?

Number of seats

Is the vehicle left hand drive?

Please enter the postcode where the vehicle is normally kept overnight?

Security

Does this vehicle have an alarm fitted?

Does this vehicle have an immobiliser fitted?

Does this vehicle have a tracking device fitted?

If another security device is fitted, who fitted it?

If another security device is fitted, who manufactured it?