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 HirePublic Hire Proposer/Driver 1 First Name Last Name * Date of Birth * Marital status Choose one SingleMarriedSeperatedWidowed 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 year2 years3 years4 years5 years6 years7 years8 years9 years10 years or more No Claim Bonus * Choose one None1 Year Taxi2 Year Taxi3 Year Taxi4 Year Taxi5 Year Taxi1 Year Private Car2 Year Private Car3 Year Private Car4 Year Private Car5 Year Private Car Have you had any Fault/Non-fault claims in the last 5 years? * Choose one NoYes Have you had any Motor Convictions in the last 5 years? * Choose one NoYes Add additional driver? NoYes Driver 1: Motor Convictions in the last 5 years Conviction code Please select AC10AC20AC30BA10BA30CD10CD20CD30CD40CD50CD60CD70CD71CU10CU20CU30CU40CU50CU80DD30DD40DD60DD70DD80DR10DR20DR30DR40DR50DR60DR70DR80DR90IN10LC20LC30LC40LC50MS10MS20MS30MS40MS50MS60MS70MS80MS90MW10PC10PC20PC30SP10SP20SP30SP40SP50SP60TS10TS20TS30TS40TS50TS60TS70UT10UT20UT30UT40UT50TT99XX99 Conviction date Fine amount Banned Choose one FaultNon-fault 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 1: 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 Additional Driver Relation with Policy Holder EmployeeSpouse First Name Last Name Date of birth Home Address Number of Years Resident in UK 1 year2 years3 years4 years5 years6 years7 years8 years9 years10+ years Marital status Choose one SingleMarriedSeperatedWidowed 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 None1 year2+ 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
