Motor Trade Insurance Quotation Form Motor Trade Insurance Quotation Form Proposer Details Proposer Full Name * Business Status * Choose one Sole Trader Partnership Limited Company Trading name Telephone / Mobile no. * Email * Correspondence Address * Postal Code * Trading Address different from correspondence address? * No Yes Trading Address Postal Code Business activity + Cover Nature of Business (select at least one) * Vehicle Sales & Repairs Vehicle Purchase & Resale MOT Testing Breakdown Recovery Delivery/Collection Cover type * Select cover type Comprehensive Third Party Fire & Theft Vehicle Indeminity * Select vehicle indeminity £5,000 £7,500 £10,000 £12,500 £15,000 £20,000 £25,000 £30,000 £35,000 £40,000 Excess £500 £1000 Demonstration cover * Select one Required Not required No Claim Bonus * None 1 Year Motor Trade 2 Year Motor Trade 3 Year Motor Trade 4 Year Motor Trade 5 Year Motor Trade 1 Year Private Car 2 Year Private Car 3 Year Private Car 4 Year Private Car 5 Year Private Car Add additional driver(s)? * Choose one 0 1 2 3 4 Proposer No Claims Bonus Number of years NCB None 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years NCB earned on policy type Choose one Taxi Private car Motor Trade Van Other NCB earned on policy type Policy expiry date Proposer/Driver 1 First Name * Last Name * Date of Birth * Home Address * Number of years resident in UK * 1 2 3 4 5 6 7 8 9 10+ Marital status * Choose one Single Married Seperated Widowed Driving License Number * Full UK/EU Licence Issue Date * Occupation (Full Time) Occupation (Part Time) Have you had any motor convictions in the last 5 years? * Choose one No Yes Have you had any Fault/Non-fault claims in the last 5 years? * Choose one No Yes Driver 1: Motor Convictions in last 5 years Conviction code Please select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CD71 CU10 CU20 CU30 CU40 CU50 CU80 DD30 DD40 DD60 DD70 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 UT10 UT20 UT30 UT40 UT50 TT99 XX99 Conviction date Fine amount Banned No Yes Add Remove Driver 1: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one Fault Non-fault Add Remove Driver 2 Relation with Policy Holder Employee Business Partner Spouse First Name Last Name Date of birth Home Address Number of years resident in UK 1 2 3 4 5 6 7 8 9 10+ Marital status Choose one Single Married Seperated Widowed Driving License Number Full UK Driving licence issue date Occupation (full time) Occupation (part time) Has the additional driver 2 had any motor convictions in the last 5 years? * Choose one No Yes Has the additional driver 2 had any Fault/Non-fault claims in the last 5 years? * Choose one No Yes Driver 2: Motor Convictions in last 5 years Conviction code Please select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CD71 CU10 CU20 CU30 CU40 CU50 CU80 DD30 DD40 DD60 DD70 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 UT10 UT20 UT30 UT40 UT50 TT99 XX99 Conviction date Fine amount Banned No Yes Add Remove Driver 2: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one Fault Non-fault Add Remove Driver 3 Relation with Policy Holder Employee Business Partner Spouse First Name Last Name Date of birth Home Address Number of years resident in UK 1 2 3 4 5 6 7 8 9 10+ Marital status Choose one Single Married Seperated Widowed Driving License Number Full UK Driving licence issue date Occupation (full time) Occupation (part time) Has the additional driver 3 had any motor convictions in the last 5 years? * Choose one No Yes Has the additional driver 3 had any Fault/Non-fault claims in the last 5 years? * Choose one No Yes Driver 3: Motor Convictions in last 5 years Conviction code Please select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CD71 CU10 CU20 CU30 CU40 CU50 CU80 DD30 DD40 DD60 DD70 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 UT10 UT20 UT30 UT40 UT50 TT99 XX99 Conviction date Fine amount Banned No Yes Add Remove Driver 3: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one Fault Non-fault Add Remove Driver 4 Relation with Policy Holder Employee Business Partner Spouse First Name Last Name Date of birth Home Address Number of years resident in UK 1 2 3 4 5 6 7 8 9 10+ Marital status Choose one Single Married Seperated Widowed Driving License Number Full UK Driving licence issue date Occupation (full time) Occupation (part time) Has the additional driver 4 had any motor convictions in the last 5 years? * Choose one No Yes Has the additional driver 4 had any Fault/Non-fault claims in the last 5 years? * Choose one No Yes Driver 4: Motor Convictions in last 5 years Conviction code Please select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CD71 CU10 CU20 CU30 CU40 CU50 CU80 DD30 DD40 DD60 DD70 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 UT10 UT20 UT30 UT40 UT50 TT99 XX99 Conviction date Fine amount Banned No Yes Add Remove Driver 4: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one Fault Non-fault Add Remove Driver 5 Relation with Policy Holder Employee Business Partner Spouse First Name Last Name Date of birth Home Address Number of years resident in UK 1 2 3 4 5 6 7 8 9 10+ Marital status Choose one Single Married Seperated Widowed Driving License Number Full UK Driving licence issue date Occupation (full time) Occupation (part time) Has the additional driver 5 had any motor convictions in the last 5 years? * Choose one No Yes Has the additional driver 5 had any Fault/Non-fault claims in the last 5 years? * Choose one No Yes Driver 5: Motor Convictions in last 5 years Conviction code Please select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CD71 CU10 CU20 CU30 CU40 CU50 CU80 DD30 DD40 DD60 DD70 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 UT10 UT20 UT30 UT40 UT50 TT99 XX99 Conviction date Fine amount Banned No Yes Add Remove Driver 5: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one Fault Non-fault Add Remove Declaration Have you or any other person who may drive: Any defect in vision, hearing, mental or physical, infirmity, disorder or disease (Including diabetes, Epilepsy or Heat Condition) * Choose one option Yes No Have been charged/convicted of any motoring or other criminal offence or is any prosecution pending? * No Yes Had a proposal declined, policy voided/cancelled, renewal refused or been required to pay an increased premium or had special terms imposed by a motor insurer? * Choose one option Yes No Send
