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Performance Insurance: Motor Insurance Quote Form
All quotations are based on Annual policies, offering exceptional solutions to your insurance needs.
Annual No Claims Bonus awarded for claim free driving
Instalment Plans available
Short Term Policies for 3 and 6 Months cover are available on request
Policy Holder Details:
Title
Full Name
Postcode
House Number / Name
Road Name
Town / City
Email Address
Telephone No.
Would you like us to contact you by Email/Telephone?
Email
Phone
When would you like us to contact you?
Vehicle Details:
Who is the owner & registered keeper of the vehicle (e.g. Policy Holder / Spouse)?
Vehicle Registration
Estimated vehicle value?
Has the vehicle been Modified?
Yes
No
Has the vehicle been Imported?
Yes
No
Has the vehicle been Q Plated?
Yes
No
If so, please provide further details
Make (e.g. Ford)
Model (e.g. Focus)
Variation (e.g. LX)
Engine Size (e.g. 1.8i / 1796cc)
Fuel Type (e.g. Petrol)
Petrol
Diesel
LPG
Year of Manufacture (e.g. 1999)
Number of doors (e.g. 5 dr)
2 Doors
3 Doors
4 Doors
5 Doors
Body Type (e.g. Hatchback)
Transmission (e.g. Manual)
Manual
Automatic
Number of seats (e.g. 5)
2
3
4
5
6
7
Is the vehicle Right hand Drive
Please select
Yes
No
Purchase Date (e.g. 01/04/2003)
Security Details:
Where will the vehicle be kept overnight (e.g. Garage)
Garage
Parked on Drive
Public Road
Other
Will the vehicle be kept at the home address
Yes
No
If no, please provide further details:
Is the vehicle fitted with manufacturers Immobiliser/Alarm
Yes
No
Has the vehicle been fitted with a Thatcham Approved Security Device
Yes
No
if yes, which catergory
1
2
3
4
5
Is the vehicle fitted with an activated tracking device
Yes
No
If so, please provide specification (e.g. Navtrak)
Cover Details:
Cover Date
Is this a Renewal Date
Yes
No
Level of Cover
Please Select
Comprehensive
Third Party Fire & Theft
Third Part Only
Voluntary Excess
Who will drive the vehicle
Insured Only
Insured & Named
Any Driver over 25
How many years 'No Claims Bonus' is available for this policy
0
1
2
3
4
5
6
7
8
9
10
Country of issue
UK
EU
Other
'NCB' Protection (min 5yrs)
Yes
No
Driver Details:
Sex
Male
Female
DOB
Marital Status
Please Select
Married
Single
Divorced
Widowed
Co-Habitating
Years licence held
Homeowner
Yes
No
Home Insurance Renewal Date
May we contact you regarding this?
Yes
No
Employment Status (e.g Employed)
Please Select
Employed
Self Employed
Unemployed
Not in Employment
Voluntary Worker
Occupation (e.g. Sales Manager)
Employers Business (e.g. Manufacturing)
Do you use the vehicle to travel to & from a single place of work:
Yes
No
Do you use the vehicle for Business use atall
Yes
No
If yes, please provide further details:
Private Mileage (annual)
Business Mileage (Annual)
Use of other vehicles
Yes
No
Driving experience If driven similar vehicles please provide full details (including Model type & years owned)
Owners Clubs
Yes
No
Any accidents, Claims or Losses within the last 5 years
Yes
No
If yes, Please give details below
Incident 1
Date: Was the driver at fault?: Claim Amount: £ Description:
Incident 2
Date: Was the driver at fault?: Claim Amount: £ Description:
Incident 3
Date: Was the driver at fault?: Claim Amount: £ Description:
Any Motoring convictions / Penalty Points / Disqualifications
Yes
No
If Yes, Please give details below
Incident 1
Date: Conviction Code: Fine: £ Points: Disqualification Period:
Incident 2
Date: Conviction Code: Fine: £ Points: Disqualification Period:
Incident 3
Date: Conviction Code: Fine: £ Points: Disqualification Period:
Any Medical Conditions the DVLA need to be aware of
Yes
No
Additional Driver Details:
Name
Relationship
Sex
Male
Female
DOB
Marital Status
Please Select
Married
Single
Divorced
Widowed
Years licence held
Homeowner
Yes
No
Home Insurance Renewal Date
May we contact you regarding this?
Yes
No
Employment Status (e.g Employed)
Occupation (e.g. Sales Manager)
Employers Business (e.g. Manufacturing)
Class of Use
Private Mileage (annual)
Business Mileage (Annual)
Use of other vehicles
Yes
No
Driving experience If driven similar vehicles please provide full details (including Model type & years owned)
Owners Clubs
Yes
No
Any accidents, Claims or Losses within the last 5 years
Yes
No
If Yes, Please give details below
Incident 1
Date: Was the driver at fault?: Claim Amount: £ Description:
Incident 2
Date: Was the driver at fault?: Claim Amount: £ Description:
Incident 3
Date: Was the driver at fault?: Claim Amount: £ Description:
Any Motoring convictions / Penalty Points / Disqualifications
Yes
No
If Yes, Please give details below
Incident 1
Date: Conviction Code: Fine: £ Points: Disqualification Period:
Incident 2
Date: Conviction Code: Fine: £ Points: Disqualification Period:
Incident 3
Date: Conviction Code: Fine: £ Points: Disqualification Period:
Any Medical Conditions the DVLA need to be aware of
Yes
No
How can we help you?:
We use an extensive range of underwriters in order to provide you with the best Policy / Quotation available
Please provide details of:
Best Quote
Excess
Company
Cover
Additional Information:
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