Renewal Date of Existing Insurance Name of proposer Address Phone No. (H) Phone No. (W) Business Address Email Date of Birth Age Martial Status Occupation Type of Licence held Full How long is licence held? Any accidents, claims, convictions? Yes If so, please fill in the following:
Date Circumstances Cost of claim DETAILS OF OTHER DRIVERS (1) Name Relationship to proposar Date of Birth Age Occupation Type of licence Full How long is licence held Any accidents, claims or convictions Yes If so, please fill in the following:
Date Circumstances Cost of claim (2) Name Relationship to proposar Date of Birth Age Occupation Type of licence Full How long is licence held Any accidents, claims or convictions Yes If so, please fill in the following:
Date Circumstances Cost of claim (3) Name Relationship to proposar Date of Birth Age Occupation Type of licence Full How long is licence held Any accidents, claims or convictions Yes If so, please fill in the following:
Date Circumstances Cost of claim DETAILS OF VEHICLE Make Model Petrol or Diesel Year of Make Type of Body ie. Car/Van Cubic Capacity Value Do you or your spouse have full-time use of any other motor vehicle Yes If so, please give details: Make Model Cubic capacity No claims bonus Do any drivers hav any physical defects or infirmities? Yes If so, please give details Are all the drivers non drinkers? Yes Are you a smoker? Yes Are you a homeowner? Yes How many years no claim bonus have you? How many years have you been insured as a named driver? Name of present insurers? Present Premium What is the most competitive quote you have? From whom? What type of cover do you require: Third Party, Third Party Fire and Theft or Comprehensive? Please Choose Third Party Third Party Fire and Theft Comprehensive What is your estimated annual mileage? Is vehicle used for private or business purposes? Date of application for quotation
