Taxi Quotation Form Taxi Quotation Form Proposer Details Proposer Full Name * Telephone / Mobile no. * Email * Home Address * Postal Code * Vehicle Required Cover – Comprehensive / Third Party Fire & Theft * Registration No. * Make & Model * Estimated Value * Purchase Date * No of Seats * Vehicle Owner * Vehicle Keeper * Usage – Private or Public Hire Private Hire Public Hire Proposer/Driver 1 First Name Last Name * Date of Birth * Marital status Choose one Single Married Seperated Widowed Driving Licence No * Full UK/EU Licence Issue Date * Occupation (part time) Occupation (full time) Taxi Badge Issue Date Taxi Licence Issuing Authority Period of Private/Public Hire Experience 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years or more No Claim Bonus * Choose one None 1 Year Taxi 2 Year Taxi 3 Year Taxi 4 Year Taxi 5 Year Taxi 1 Year Private Car 2 Year Private Car 3 Year Private Car 4 Year Private Car 5 Year Private Car Have you had any Fault/Non-fault claims in the last 5 years? * Choose one No Yes Have you had any Motor Convictions in the last 5 years? * Choose one No Yes Add additional driver? No Yes Driver 1: Motor Convictions in the 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 Choose one Fault Non-fault 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 1: 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 Additional Driver Relation with Policy Holder Employee Spouse First Name Last Name Date of birth Home Address Number of Years Resident in UK 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10+ years Marital status Choose one Single Married Seperated Widowed Driving License Number Full UK Drinving license issue date Occupation (full time) Occupation (part time) Taxi Badge Issue Date Taxi Badge Licensing Authority/Council Taxi Experience None 1 year 2+ years Fault/Non Fault claims in last 5 years Please provide claim date, incident details, amount, fault/nonfault. Motor Convictions in last 5 years Please provide incident date, incident details, amount, fault/nonfault. Add driver Remove driver Declaration Have you or any person who may drive: Any defect in vision, hearing, mental or physical, infirmity, disorder or disease (including diabetes, epilepsy or heat condition)? * Yes No Have been charged/convicted of any motoring or other criminal offence or is any prosecution pending? * Yes No 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? * Yes No Send
