Quote4Insurance
Car Insurance
Section 1 - Client Details
Title
Mr.
Mrs.
Miss
Dr.
Rev.
Surname
First Names
Date of Birth
Address
Town
City
County
Postcode
Email
Home Telephone
Section 2 - Car Insurance
Cover Required
Third Party Fire & Theft
Third Party Only
Fully Comprehensive
Renewal Date (DD/MM/YYYY)
How Long Full Licence Held
Years
Months
Number of Drivers
and Ages
How Long Since Youngest Passed Test
Number of Cars Owned
(For Multi Car Discount)
Make of Car
Model
CC of Car
Saloon
Hatch
Other
Number of Doors
Manual / Automatic
Automatic
Manual
Age of Car
Date Car Registered
Value of Car £
Car Reg No.
Garaged ?
Yes
No
Immobilizer ?
Yes
No
Type of Immobilizer
Immobilizer Fitting From New?
Yes
No
Years of Claim Discount £
Protected NCD ?
Yes
No
Used for Business ?
Yes
No
Clock Mileage Reading
Annual Mileage
Business Mileage
Proposer's Occupation
Employment
Self Empolyment
Other Driver's Occupation
Employment
Self Empolyment
Existing Breakdown Cover?
Yes
No
Cover With
AA
RAC
Other
Other
Do you pay separately for this cover
Yes
No
If so, how much?
Present Company
Premium Paying (approx) £
Remarks (include other facts i.e. poor sight/ illness /other handicap or disability)
Driving History (include past Claims / Accidents / Convictions)
How did you hear of
Quote4insurance
?
e.g. Name of magazine/newspaper you saw our advert in,
T.V., radio, Teletext,diverted from other site = please name site, internet advert etc.