Van Insurance Quote Form

Proposer’s Details

Title:

First name:

Surname:

Address:

Postcode:

Date of Birth:

Driving Status:

Occupation:

Employers Business Type:

Job Status:

Marital Status:

Number Of Years Continuously Lived In UK Prior To Start Date: (Years)

Licence Type:

Proposers Driving Licence Number:

Period This Licence Type Held: (Years)

Do You Have Use Of Any Other Vehicles:

What Will You Use The Vehicle For:

What Will Be The Estimated Annual Mileage Of The Van:

Do You Own Your Own Home:

YesNo

Is the van to be insured in company name:

YesNo

If Yes: What is the company name:

Vehicle Details

Registration Number (if known):

Body Type:

Make (e.g. Ford):

Model (e.g. T220):

Exact Model Type (e.g. Connect TDI, Double Cab 4X4, etc):

Engine Size (ccs):

Gross Vehicle Weight (kg):

Carrying Capacity (kg):

Year Of Manufacture:

Value £

Number of Doors:

Number of Seats:

Fuel Type:

Date Of Purchase or Intended Purchase Date:

Vehicle Security:

Transmission:

Overnight Parking:

Any Modifications:

YesNo

If Yes: Please State Full Modifications:

Is the vehicle fitted with a winch or hoist?

YesNo

Who Will Drive The Car:

(If Additional Drivers -)

First Additional Driver Details (If Applicable)

Title:

First name:

Surname:

Date of Birth:

Driving Status:

Occupation:

Employers Business Type:

Job Status:

Marital Status:

Number Of Years Continuously Lived In UK Prior To Start Date: (Years)

Licence Type:

Driver's Driving Licence Number:

Period This Licence Type Held: (Years)

Do You Have Use Of Any Other Vehicles:

What Will You Use The Vehicle For:

Do You Own Your Own Home:

YesNo

Relationship To Proposer:

Second Additional Driver Details (If Applicable)

Title:

First name:

Surname:

Date of Birth:

Driving Status:

Occupation:

Employers Business Type:

Job Status:

Marital Status:

Number Of Years Continuously Lived In UK Prior To Start Date: (Years)

Licence Type:

Driver's Driving Licence Number:

Period This Licence Type Held: (Years)

Do You Have Use Of Any Other Vehicles:

What Will You Use The Vehicle For:

Do You Own Your Own Home:

YesNo

Relationship To Proposer:

Third Additional Driver Details (If Applicable)

Title:

First name:

Surname:

Date of Birth:

Driving Status:

Occupation:

Employers Business Type:

Job Status:

Marital Status:

Number Of Years Continuously Lived In UK Prior To Start Date: (Years)

Licence Type:

Driver's Driving Licence Number:

Period This Licence Type Held: (Years)

Do You Have Use Of Any Other Vehicles:

What Will You Use The Vehicle For:

Do You Own Your Own Home:

YesNo

Relationship To Proposer:

Previous Incidents

Have Any Drivers Had Any Accidents, Fire, Theft, Claims Or Reported Incidents In The Last 5 Years:

YesNo

(If Yes Need to Know For Each Incident:)

Incident 1

Who Had The Incident:

Incident Date:

Incident Type:

Was A Recovery Of Costs Made From Third Party:

Own Damage Costs: £

Did The Incident Affect Your No Claims Bonus:

YesNo

Was The Driver At Fault For The Incident:

Did The Incident Involve Any Personal Injury:

YesNo

What Were The Third Partys Costs (if applic): £

Under Which Policy Was The Claim Made:

Description Of Incident:

Incident 2

Who Had The Incident:

Incident Date:

Incident Type:

Was A Recovery Of Costs Made From Third Party:

Own Damage Costs: £

Did The Incident Affect Your No Claims Bonus:

YesNo

Was The Driver At Fault For The Incident:

Did The Incident Involve Any Personal Injury:

YesNo

What Were The Third Partys Costs (if applic): £

Under Which Policy Was The Claim Made:

Description Of Incident:

Incident 3

Who Had The Incident:

Incident Date:

Incident Type:

Was A Recovery Of Costs Made From Third Party:

Own Damage Costs: £

Did The Incident Affect Your No Claims Bonus:

YesNo

Was The Driver At Fault For The Incident:

Did The Incident Involve Any Personal Injury:

YesNo

What Were The Third Partys Costs (if applic): £

Under Which Policy Was The Claim Made:

Description Of Incident:

Incident 4

Who Had The Incident:

Incident Date:

Incident Type:

Was A Recovery Of Costs Made From Third Party:

Own Damage Costs: £

Did The Incident Affect Your No Claims Bonus:

YesNo

Was The Driver At Fault For The Incident:

Did The Incident Involve Any Personal Injury:

YesNo

What Were The Third Partys Costs (if applic): £

Under Which Policy Was The Claim Made:

Description Of Incident:

Incident 5

Who Had The Incident:

Incident Date:

Incident Type:

Was A Recovery Of Costs Made From Third Party:

Own Damage Costs: £

Did The Incident Affect Your No Claims Bonus:

YesNo

Was The Driver At Fault For The Incident:

Did The Incident Involve Any Personal Injury:

YesNo

What Were The Third Partys Costs (if applic): £

Under Which Policy Was The Claim Made:

Description Of Incident:

Previous Convictions

Have Any Drivers Had Any Motoring Convictions e.g. speeding, In The Last 5 Years:

YesNo

If yes Need To Know Following Details:

Conviction 1

Who Had The Conviction:

Offence Date:

Conviction Date:

Conviction Code e.g. SP30:

Fine: £

Disqualified:

YesNo

How Many Penalty Points:

Conviction 2

Who Had The Conviction:

Offence Date:

Conviction Date:

Conviction Code e.g. SP30:

Fine: £

Disqualified:

YesNo

How Many Penalty Points:

Conviction 3

Who Had The Conviction:

Offence Date:

Conviction Date:

Conviction Code e.g. SP30:

Fine: £

Disqualified:

YesNo

How Many Penalty Points:

Conviction 4

Who Had The Conviction:

Offence Date:

Conviction Date:

Conviction Code e.g. SP30:

Fine: £

Disqualified:

YesNo

How Many Penalty Points:

Conviction 5

Who Had The Conviction:

Offence Date:

Conviction Date:

Conviction Code e.g. SP30:

Fine: £

Disqualified:

YesNo

How Many Penalty Points:

Other Driver Info

Has Any Driver Got Any Disabilities Or Health Issues Notifiable To DVLA:

YesNo

If Yes: Please fully list health issues:

General Details

Cover Required:

How Many Years No Claims Bonus For This Vehicle:

Do You Want To Protect The Above No Claims Bonus:

YesNo

How Many Years No Claims Bonus Do You Have On Another Owned Vehicle (If Applic):

Address Where Van Will Be Kept Overnight:

Postcode Where Van Will Be Kept Overnight:

What Date Is Cover Required From:

Current Insurer (If Applicable):

Renewal Premium or Current Best Quote: £

Consent For Credit Check Declaration:

Yes

Consent For MyLicence Check Declaration:

Yes

Your Contact Details

Full Contact Name:

Telephone number:

Email address:

How Would You Prefer Us To Contact You About Our Best Quotation:

Van Insurance Quote Form

Proposer’s Details

Vehicle Details

(If Additional Drivers -)

First Additional Driver Details (If Applicable)

Second Additional Driver Details (If Applicable)

Third Additional Driver Details (If Applicable)

Previous Incidents

Incident 1

Incident 2

Incident 3

Incident 4

Incident 5

Previous Convictions

Conviction 1

Conviction 2

Conviction 3

Conviction 4

Conviction 5

Other Driver Info

General Details

Your Contact Details

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