Van / Commercial Vehicle Insurance Quotation Form

Please complete as much of this form as possible as it will allow us to provide you with the most competitive quotation. Fields marked with an * are required.

Contact Details

Full Name*

Company Name (if applicable)


House Number or Name*

Street Name*

Postal Town*


Post Code*

Telephone Number*

Email Address*

Best method to contact you

Contact me by

Telephone E-Mail

If by Telephone please select

Best Days

Monday Tuesday Wednesday Thursday Friday Saturday

Best Time

Any Time 9am - Noon Noon - 3:00pm 3:00pm - 6:00pm

Your Details

Occupation/Nature of Business*

Date of Birth*

Marital Status*


Yes No

Full UK Driving Licence

Yes No

Length of time licence held*

Do you or any person who may drive have any convictions or fixed penalties in the last 5 years?

Yes No

Hve you or any person who may drive had any Accidents or Losses in the last 5 years, regardless of blame?

Yes No

If yes to any of the above please give brief details including dates, conviction codes, fines, incident circumstances and costs etc.

Vehicle Details

Vehicle Registration*

Vehicle Make*

Exact Vehicle Model*

Engine Size*

Fuel Type

Petrol Diesel LPG

Year of Make*

Vehicle Value*

Body Type*

If other, please give detail

Purchase Date*

Annual Mileage*

Where is the vehicle kept overnight?*

Cover and Drivers

Cover Required*

Vehicle Use*


Other Drivers (if applicable)


Date of Birth(s)


Type of Licence (e.g Full UK, Prov, EU) and years held

Insurance History and No Claims Bonus

What is the renewal date of your current policy or when did your last policy expire?*

Name of your current / last Insurer?*

What is your Renewal / Expiring premium?*

No Claims Bonus, number of years*

Protected No Claims Bonus

Yes No

Please confirm you have read the Fair Processing Notice before submitting this quotation request*

Please enter the phrase as it is shown in the box above.   


 Henderson Insurance (NE) Limited Fair Processing Notice

In your dealings with us you may provide information that includes data that is known as personal data.
The personal data we collect will include data relating to your name, address, date of birth, wider contact details and data relating to ‘health’ or ‘criminal offences’.

We will process your personal data to allow us to provide you with our services as your insurance broker in quoting for, arranging and administering your insurances and in arranging insurance premium finance, where applicable.

It will also be used to manage future communications between ourselves and communicate about our products and services. You can opt out from receiving such communications services by emailing

We will only use your data for the purpose for which it was collected. We will only grant access to or share your data within our firm, with authorised partners, and our market service providers such as insurers and premium finance providers where we are required or entitled to do so by law under lawful data processing.

If you require further information on how we process your data and our lawful basis for doing so, please contact our ‘data privacy representative’ by emailing or view our Privacy Notice at