Motor Quote Request Form
(
Required fields)
Title
Mr
Mrs
Ms
Miss
Forename
Surname
No and Street
District
Town City
Post Code
Tel
Fax
Mobile
email
D.O.B
Occupation
Company Name
Nature of Business
Start of cover
Current Insurer
Price to beat
Motor Car Insurance
Licence Type
Full
Provisional
How long have you held your licence
Years
Are you the registered owner & keeper ?.
Yes
No
Are you the main driver
Yes
No
Annual Mileage
Miles
Vehicle Details
Make
Model
Type (Coupe etc)
Engine Size
Fuel Type
Petrol
Diesel
Year
Gears
Manual
Automatic
No. of Doors
Value
Registration
Is this a second car
No
Yes
Left Hand Drive
No
Yes
Alarmed ?
No
Yes
Alarm Make
Immobiliser ?
No
Yes
Manufacturer
Has the vehicle been modified from the manufacturers specification, i.e. Alloy wheels, spoiler etc. If yes give details below.
No
Yes
If yes enter details.
Additional Drivers
Driver 1
Driver 2
Driver 3
Name
Date of Birth
Relationship to proposer
Spouse
Child
C.law Spouse
Parent
Family
Unrelated
Spouse
Child
c.law spouse
Parent
Family
Unrelated
Spouse
Child
C.law Spouse
parent
Family
Unrelated
Employment Status
Employed
Unemployed
Retired
Student
Self Employed
Employed
Unemployed
Retired
Student
Self Employed
Employed
Unemployed
Retired
Student
Self Employed
Occupation
Business
Type of Licence
Full
Provisional
Full
Provisional
Full
Provisional
Period Held (years and months)
General Questions
Do any of the drivers suffer from any medical conditions?
If yes please give details below
No
Yes
Have any drivers had any claims in the last 5 years?
If yes please give details below
No
Yes
Have any driver been convicted of a motoring offence?
If yes please give date, reason and number of points below.
No
Yes
Have any drivers been resident outside of the UK or
been born outside of the UK If yes please give details below
No
Yes
If any enter details of Medical, Claims, Offences or Residency.
Insurance Details
Cover Type
Comprehensive
Third Party Fire & Theft
third party only
Voluntary Excess
No Claim Bonus
0
1
2
3
4
5
6
Years
Protected Bonus Required
No
Yes
Will the vehicle be used for Social, Domestic & Pleasure purposes?
Yes
No
Will the vehicle be used for Commuting to one permanent place of work
No
Yes
Will the vehicle be used in Connection with your work or Business
No
Yes
If any enter details of domestic, work or any business use ?
Additional Details
Please include further details which you feel may affect your insurance premium ?
Name any Motoring Organisations you belong to ?
Where is your Car kept overnight ?
Garaged
Driveway
Road
Message
Please state any other relevant information in this space.
Authorised and regulated by the Financial Services Authority
Anthola Insurance Agency (U.K.) Ltd
sales@anthola.co.uk
website by
http://www.specialistwebdesign.com