Performance Insurance Direct

       
Commercial Insurance Direct: Quote Form
Full Name: DOB:
Address:    
Daytime Phone:
Work Phone:
Mobile:
E-Mail Address:
If you only need information: about this type of insurance and do not want to fill out this entire form please fill out the next box and tell us what information you require. Then click on 'GO', which will take you to the bottom of this page. You should then click on the 'Submit' button which will send us your details. (If this does not apply, please carry on with your details).
Information Required: Click on submit at base of page.
Vehicle Details:
Catergory: Vehicle:
Make: Model:
G.V.W: Capacity:
Engine Size: Registration:
Fuel: Transmission:
Number of Doors: Number of Seats:
Year: Body Type:
  Type (XR31, GLX):
Value:    
       
Container(s): Yes No Trailers: Yes No
Winch/Hoist: Yes No Radius:
Windscreen Cover: Yes No    
Alarm Details:
Alarm Fitted: Yes No    
Model Fitted: Fitted By:
Immobiliser: Yes No    
Model Fitted: Fitted By:
Tracking Dev: Yes No    
Model Fitted: Fitted By:
       
Parking: Reg Owner:
    Other... :
    Reg Keeper:
  Other... :
  Who will Drive:
Age of Youngest Driver: Policy Length:
Is Policy to be in Company Name: Yes No  
Proposer Details:
Sex: M F DOB:
Driving Status: Occupation:
Business: Status:
    Employed:
Personal Details:
Marital status: Length of residency:
Country of origin: Licence type:
Length Licence held: Country Issued:
Vehicle Useage:
All Policies have Social, Domestic and Pleasure use:  
Type of Use: Private Mileage:
Business Mileage: Home Owner: Yes No
Renewal Date:    
Contents Sum Insured:
Buildings Sum Insured:
Smoker: Yes No Drinker: Yes No
Do you have use of any other vehicle: Yes No
Whose car do you use: Other:
Renewal Date:
       
Have you suffered any loss during the past 5 years regardless of blame, this includes lost by Theft, Accident, Fire, Malicious or Accidental. Yes No
       
How many accidents have you been involved in?:
Date of loss: Type:
Damage to your vehicle:  
Damage to third party (if applicable):  
Did your insurers recover all their costs: Yes No  
Was your no claims discount affected: Yes No  
Whose policy was the claim under:  
  Other... :
Your fault: Yes No Description:
Do you have motoring convictions in the past 11 years: Yes No
How many offences have occurred:
Date of Offence: Date of Conviction:
Fine: Points:
Length of Ban:    
       
Do you have any disabilities or Medical Infirmities: Yes No
Type of Infirmities:
Other... :
Have DVLA been notified: Yes No  
Has your driving licence been restricted: Yes No  
How long have you had your infirmity:
Has your vehicle been adapted: Yes No  
       
Cover Details:
Cover Type: Years NCB:
Type of NCB: Protected NCB: Yes No
Parking Post Code: Renewal Date:
       
 
Copyright © 2002 Mayfair Insurance & Mortgage Consultants Ltd. Reg. 2275219
An independent intermediary for a number of insurers.
     
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