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)

Address

House Number or Name*

Street Name*

Postal Town*

County

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*

Please Select...MarriedSingleCommon LawPartneredPartnered - CivilWidowedDivorcedSeparated

Homeowner

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*

Please Select...VanPickupDouble Cab Pick UpTipperOther

If other, please give detail

Purchase Date*

Annual Mileage*

Please Select...1000-50005000-80008000-10,00010,000-12,00012,000-15,000Over 15,000

Where is the vehicle kept overnight?*

Please Select...GaragedDrivewayCarportYard / CompoundRoadside

Cover and Drivers

Cover Required*

Please Select...ComprehensiveThird Party Fire and TheftThird Party Only

Vehicle Use*

Please Select...Carriage of Own Goods UseCarriage of Goods for Hire and RewardLocal HaulageLong Distance HaulageCourier Use

Drivers*

Please Select...Insured OnlyInsured and SpouseNamed DriversAny Driver 25 and OverAny Driver inc Declared Drivers Under 25

Other Drivers (if applicable)

Name(s)

Date of Birth(s)

Occupation(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*

Please Select...123456789

Protected No Claims Bonus

Yes No

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