Motor Trade Insurance Quotation Form Motor Trade Insurance Quotation Form Proposer Details Proposer Full Name * Business Status * Choose one Sole TraderPartnershipLimited 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 ComprehensiveThird 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 RequiredNot required No Claim Bonus * None1 Year Motor Trade2 Year Motor Trade3 Year Motor Trade4 Year Motor Trade5 Year Motor Trade1 Year Private Car2 Year Private Car3 Year Private Car4 Year Private Car5 Year Private Car Add additional driver(s)? * Choose one 01234 Proposer No Claims Bonus Number of years NCB None1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years NCB earned on policy type Choose one TaxiPrivate carMotor TradeVanOther 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 * 12345678910+ Marital status * Choose one SingleMarriedSeperatedWidowed 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 NoYes Have you had any Fault/Non-fault claims in the last 5 years? * Choose one NoYes Driver 1: Motor Convictions in last 5 years Conviction code Please select AC10AC20AC30BA10BA30CD10CD20CD30CD40CD50CD60CD70CD71CU10CU20CU30CU40CU50CU80DD30DD40DD60DD70DD80DR10DR20DR30DR40DR50DR60DR70DR80DR90IN10LC20LC30LC40LC50MS10MS20MS30MS40MS50MS60MS70MS80MS90MW10PC10PC20PC30SP10SP20SP30SP40SP50SP60TS10TS20TS30TS40TS50TS60TS70UT10UT20UT30UT40UT50TT99XX99 Conviction date Fine amount Banned NoYes Add Remove Driver 1: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one FaultNon-fault Add Remove Driver 2 Relation with Policy Holder EmployeeBusiness PartnerSpouse First Name Last Name Date of birth Home Address Number of years resident in UK 12345678910+ Marital status Choose one SingleMarriedSeperatedWidowed 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 NoYes Has the additional driver 2 had any Fault/Non-fault claims in the last 5 years? * Choose one NoYes Driver 2: Motor Convictions in last 5 years Conviction code Please select AC10AC20AC30BA10BA30CD10CD20CD30CD40CD50CD60CD70CD71CU10CU20CU30CU40CU50CU80DD30DD40DD60DD70DD80DR10DR20DR30DR40DR50DR60DR70DR80DR90IN10LC20LC30LC40LC50MS10MS20MS30MS40MS50MS60MS70MS80MS90MW10PC10PC20PC30SP10SP20SP30SP40SP50SP60TS10TS20TS30TS40TS50TS60TS70UT10UT20UT30UT40UT50TT99XX99 Conviction date Fine amount Banned NoYes Add Remove Driver 2: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one FaultNon-fault Add Remove Driver 3 Relation with Policy Holder EmployeeBusiness PartnerSpouse First Name Last Name Date of birth Home Address Number of years resident in UK 12345678910+ Marital status Choose one SingleMarriedSeperatedWidowed 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 NoYes Has the additional driver 3 had any Fault/Non-fault claims in the last 5 years? * Choose one NoYes Driver 3: Motor Convictions in last 5 years Conviction code Please select AC10AC20AC30BA10BA30CD10CD20CD30CD40CD50CD60CD70CD71CU10CU20CU30CU40CU50CU80DD30DD40DD60DD70DD80DR10DR20DR30DR40DR50DR60DR70DR80DR90IN10LC20LC30LC40LC50MS10MS20MS30MS40MS50MS60MS70MS80MS90MW10PC10PC20PC30SP10SP20SP30SP40SP50SP60TS10TS20TS30TS40TS50TS60TS70UT10UT20UT30UT40UT50TT99XX99 Conviction date Fine amount Banned NoYes Add Remove Driver 3: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one FaultNon-fault Add Remove Driver 4 Relation with Policy Holder EmployeeBusiness PartnerSpouse First Name Last Name Date of birth Home Address Number of years resident in UK 12345678910+ Marital status Choose one SingleMarriedSeperatedWidowed 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 NoYes Has the additional driver 4 had any Fault/Non-fault claims in the last 5 years? * Choose one NoYes Driver 4: Motor Convictions in last 5 years Conviction code Please select AC10AC20AC30BA10BA30CD10CD20CD30CD40CD50CD60CD70CD71CU10CU20CU30CU40CU50CU80DD30DD40DD60DD70DD80DR10DR20DR30DR40DR50DR60DR70DR80DR90IN10LC20LC30LC40LC50MS10MS20MS30MS40MS50MS60MS70MS80MS90MW10PC10PC20PC30SP10SP20SP30SP40SP50SP60TS10TS20TS30TS40TS50TS60TS70UT10UT20UT30UT40UT50TT99XX99 Conviction date Fine amount Banned NoYes Add Remove Driver 4: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one FaultNon-fault Add Remove Driver 5 Relation with Policy Holder EmployeeBusiness PartnerSpouse First Name Last Name Date of birth Home Address Number of years resident in UK 12345678910+ Marital status Choose one SingleMarriedSeperatedWidowed 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 NoYes Has the additional driver 5 had any Fault/Non-fault claims in the last 5 years? * Choose one NoYes Driver 5: Motor Convictions in last 5 years Conviction code Please select AC10AC20AC30BA10BA30CD10CD20CD30CD40CD50CD60CD70CD71CU10CU20CU30CU40CU50CU80DD30DD40DD60DD70DD80DR10DR20DR30DR40DR50DR60DR70DR80DR90IN10LC20LC30LC40LC50MS10MS20MS30MS40MS50MS60MS70MS80MS90MW10PC10PC20PC30SP10SP20SP30SP40SP50SP60TS10TS20TS30TS40TS50TS60TS70UT10UT20UT30UT40UT50TT99XX99 Conviction date Fine amount Banned NoYes Add Remove Driver 5: Fault/Non-fault claims in last 5 years Incident date Details Amount Fault/Non-fault Choose one FaultNon-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 YesNo Have been charged/convicted of any motoring or other criminal offence or is any prosecution pending? * NoYes 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 YesNo Send
