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

Proposer/Driver 1

First Name

Last Name *

Date of Birth *

Marital status

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

No Claim Bonus *

Have you had any Fault/Non-fault claims in the last 5 years? *

Have you had any Motor Convictions in the last 5 years? *

Add additional driver?

Driver 1: Motor Convictions in the last 5 years

Conviction code

Conviction date

Fine amount

Banned

Add Remove

Driver 1: Fault/Non Fault Claims in last 5 years

Incident date

Details

Amount

Fault/Non-fault

Add Remove

Driver 1: No Claims Bonus

Number of years NCB

NCB earned on policy type NCB earned on policy type

Policy Expiry Date

Additional Driver

Relation with Policy Holder

First Name

Last Name

Date of birth

Home Address

Number of Years Resident in UK

Marital status

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

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