Van Only , Cheaper Van Insurance Quote Form

		VAN INSURANCE QUOTE FORM
		This form takes approximately 5 minutes to fill in. We aim to send you a quote via email within 24hrs. If you would like immediate cover or would prefer to answer these questions over the phone, the number to call is 0800 317585.

1. Address and Contact Details
Title
First Name
Surname
Address
Postcode
Telephone Number
Email
How many years has your business been trading

2. Main Driver (Please give details of all persons including yourself who will or may drive the car)

Title
First Name
Surname
Date of Birth (dd/mm/yyyy)
Gender
Marital Status
Relationship to proposer
Occupation
Employer's business
Self-employed	Yes No
Part Time Occupation
Part Time Employer's Business
Current continuous period of UK residency	(years)
Number of vehicles driver owns or has access to
Type of Licence
If EU or other please specify country issued
Date Driving test passed or licence obtained if provisional (dd/mm/yyyy)

3. Adding other Drivers (Please go on to question 4 if you are the only driver)

Add another driver (Additional Driver ONE)

Yes No

Title
First Name
Surname
Date of Birth (dd/mm/yyyy)
Gender
Marital Status
Relationship to proposer
Occupation
Employer's business
Self-employed	Yes No
Part Time Occupation
Part Time Employer's Business
Current continuous period of UK residency	(years)
Number of vehicles driver owns or has access to
Type of Licence
If EU or other please specify country issued
Date Driving test passed or licence obtained if provisional (dd/mm/yyyy)

Add another Driver (Additional Driver TWO)

Yes No

Title
First Name
Surname
Date of Birth (dd/mm/yyyy)
Gender
Marital Status
Relationship to proposer
Occupation
Employer's business
Self-employed	Yes No
Part Time Occupation
Part Time Employer's Business
Current continuous period of UK residency	(years)
Number of vehicles driver owns or has access to
Type of Licence
If EU or other please specify country issued
Date Driving test passed or licence obtained if provisional (dd/mm/yyyy)

Add another Driver (Additional Driver THREE)

Yes No

Title
First Name
Surname
Date of Birth (dd/mm/yyyy)
Gender
Marital Status
Relationship to proposer
Occupation
Employer's business
Self-employed	Yes No
Part Time Occupation
Part Time Employer's Business
Current continuous period of UK residency	(years)
Number of vehicles driver owns or has access to
Type of Licence
If EU or other please specify country issued
Date Driving test passed or licence obtained if provisional (dd/mm/yyyy)

4. Vehicle details

Make	.............
Model (please be as accurate as possible)	.................
Number of doors	.................
Number of seats	.................
Type of body	.................
Is the vehicle left or right hand drive
Transmission	Automatic Manual
Fuel Type	.................
Engine cc	.................
Year of manufacture	.................
Annual mileage	.................
Value £	.................
Gross Vehicle Weight
Registration Number	.................
Is the vehicle owned / registered in your name	Yes No .................
If NO please give details	.................
Where is the vehicle kept	.................
Postcode of where the vehicle is kept	.................
Has the vehicle been modified or tuned	Yes No .................
If YES please give details	.................
Does the vehicle have an immobiliser ?	Yes No .................
If YES What is the make and model of the immobiliser ?	.................
When was the immobiliser fitted	.................
Who fitted the immobiliser ?	.................
Number of vehicles in household	.................
Details of other vehicles	.................
Commercial No Claims Bonus available to use on this vehicle	.................
What type of cover do you want	.................
From what date do you wish your insurance to start ? (dd/mm/yyyy)	.................

5. In addition to social, domestic and pleasure purposes, will the vehicle be used:

a	to and from one place of work by main driver?	Yes No
b	for business purposes by main driver?	Yes No
c	for business purposes by any person other than main driver?	Yes No

If you answered YES to any of question 5, give further details in the box below.
giving as much information as possible.

6. Does any person who will drive suffer from any disabilities and/or medical conditions?

Disabilities	Yes No
If YES please state condition
Number of years diagnosed with this condition
Details of any medication taken	.................
Is your licence restricted	Yes No
Have DVLA been advised	Yes No

7. Has any person who will drive been involved in a motor accident or claim in the past 5 years?

Accident 1

Yes No

Which named driver was involved?
What was the date of this accident? (dd/mm/yyyy)
What type of accident was it ?
Add further details
Were ALL of these costs reclaimed from a third party?	Yes No Pending
If No or Pending what costs (in pounds) were claimed by the driver and what costs (in pounds) were claimed by third parties for this accident?	Costs Owed/Paid to Driver
	Costs Owed/Paid to Third Party
What costs (in pounds) were claimed by the driver for personal injury ?
Was the driver's no claims bonus affected by this accident ?	Yes No Unknown
Has this driver any convictions or fixed penalty fines related to this accident?	Yes No
If YES
What was the date of the conviction?	(dd/mm/yyyy)
What is the conviction code?

What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

Accident 2 -

Yes No

Which named driver was involved?
What was the date of this accident? (dd/mm/yyyy)
What type of accident was it ?
Add further details
Were ALL of these costs reclaimed from a third party?	Yes No Pending
If No or Pending what costs (in pounds) were claimed by the driver and what costs (in pounds) were claimed by third parties for this accident?	Costs Owed/Paid to Driver
	Costs Owed/Paid to Third Party
What costs (in pounds) were claimed by the driver for personal injury ?
Was the driver's no claims bonus affected by this accident ?	Yes No Unknown
Has this driver any convictions or fixed penalty fines related to this accident?	Yes No
If YES
What was the date of the conviction?	(dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

Accident 3 -

Yes No

Which named driver was involved?
What was the date of this accident? (dd/mm/yyyy)
What type of accident was it ?
Add further details
Were ALL of these costs reclaimed from a third party?	Yes No Pending
If No or Pending what costs (in pounds) were claimed by the driver and what costs (in pounds) were claimed by third parties for this accident?	Costs Owed/Paid to Driver
	Costs Owed/Paid to Third Party
What costs (in pounds) were claimed by the driver for personal injury ?
Was the driver's no claims bonus affected by this accident ?	Yes No Unknown
Has this driver any convictions or fixed penalty fines related to this accident?	Yes No
If YES
What was the date of the conviction?	(dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

Accident 4 -

Yes No

Which named driver was involved?
What was the date of this accident? (dd/mm/yyyy)
What type of accident was it ?
Add further details
Were ALL of these costs reclaimed from a third party?	Yes No Pending
If No or Pending what costs (in pounds) were claimed by the driver and what costs (in pounds) were claimed by third parties for this accident?	Costs Owed/Paid to Driver
	Costs Owed/Paid to Third Party
What costs (in pounds) were claimed by the driver for personal injury ?
Was the driver's no claims bonus affected by this accident ?	Yes No Unknown
Has this driver any convictions or fixed penalty fines related to this accident?	Yes No
If YES
What was the date of the conviction?	(dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

8. Has any person who will drive been convicted of any motoring offences or have any prosecution pending?
Conviction 1 -	Yes No

Which named driver was involved?
What was the date of the conviction? (dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
Details of conviction
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

Conviction 2 -

Yes No

Which named driver was involved?
What was the date of the conviction? (dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
Details of conviction
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

Conviction 3 -

Yes No

Which named driver was involved?
What was the date of the conviction? (dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
Details of conviction
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

Conviction 4 -

Yes No

Which named driver was involved?
What was the date of the conviction? (dd/mm/yyyy)
What is the conviction code?
How many points were added to the driver's licence ?
Details of conviction
What fine amount was imposed?
How many months ban was imposed?	months
For Drink Driving Convictions (DR codes)
Which alcohol test did the driver undergo?
What was the reading from the test?

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