Proposer's First Name:
Proposer's Surname:
In whose name is the policy to be issued?
- - Please Select - -
Limited Company
Partnership
Sole Trader
Individual
Limited Company Name:(if policy is to be issued in a limited company name)
Business / Trade use of the vehicle:(please amend if different to 'Courier')
Business Address:
Business Postcode:
Daytime Telephone No.
E-mail Address:
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes.
Cover Details
Date Cover Required / Renewal Date: (dd/mm/yyyy)
Current Annual Premium / Best Quotation: This may help us to get you a better quote
Name of Current / Previous Insurer: e.g. Aviva, AXA, Allianz, ERS, QBE, RSA, Zurich, etc.
Date Business Established
Date business established: (dd/mm/yyyy)
Agency Drivers
Are agency drivers employed? Yes No
Business of Employer / Main Contract
Business of Employer / Main Contract:
Please Select
Independent
Amazon
DHL
DPD
Hermes
Other
Type/Category of Vehicle:
Lorry-Articulated
Lorry-Rigid Body
Motorcycle
Pick-Up
Truck-Curtainside
Van
Other
Vehicle Make (i.e. Ford, VW, etc.) :
Vehicle Model (i.e. Transit, Transporter, etc.) :
Vehicle Type (i.e. tdi, 190, 400, etc.) :
Gross Vehicle Weight (kg) :
Vehicle Engine Size (c.c.) :
Registration Number (if available) :
Year of Manufacture: (yyyy)
Date of Purchase of Vehicle: (dd/mm/yyyy)
Value of the Vehicle (£'s) :
Additional Details
Who is the registered owner of the vehicle?
Proposer
Common Law Spouse
Company
Other
Spouse
Vehicle Leasing Co.
Who is the registered keeper of the vehicle?
Proposer
Common Law Spouse
Company
Other
Spouse
Vehicle Leasing Co.
Number of seats in the vehicle:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
Fuel type:
Please Select
Petrol
Diesel
Electric
Hybrid
Hydrogen
LPG
Other
Postcode where vehicle is kept overnight:(if different from your business address)
Where is vehicle parked overnight?
- - - Please Select - - -
Car Park
Carport
Garaged
Locked Building
Locked Compound
Parked On Drive
Private Property
Public Road
Unlocked Building
Unlocked Compound
Annual mileage driven in the vehicle:
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
16,000
17,000
18,000
19,000
20,000
21,000
22,000
23,000
24,000
25,000
26,000
27,000
28,000
29,000
30,000
31,000
32,000
33,000
34,000
35,000
36,000
37,000
38,000
39,000
40,000
41,000
42,000
43,000
44,000
45,000
46,000
47,000
48,000
49,000
50,000
51,000
52,000
53,000
54,000
55,000
56,000
57,000
58,000
59,000
60,000
60,000+
Has the vehicle been imported? Yes No
If yes, please provide details of where the vehicle was imported from:
Details of immobiliser / alarm:
No Security
Manufacturer Fitted
Thatcham Category 1
Thatcham Category 2
Other Alarm or Immobiliser
Is a camera fitted?
None
Front Facing
Front & Rear Facing
Reversing aids:
None
External Warning Beep
Rear & Side Cameras
Rear View Camera
Sensors
Side View Camera
Type of goods carried:
Non-hazardous goods
Toxic/corrosive/inflammable
Radioactive materials
Other
Drop location:
Airside
Any
Builders Merchant
Dockside
Factories
Regional Distribution Centre
Residential
Rural Only
Shops / Supermarkets
Warehouses
Drop type:
Multi-Drop
Time Critical
Is the vehicle modified? Yes No
If yes, please provide details of the modifications:
Is the vehicle sign written? Yes No
Is the vehicle Left Hand Drive? Yes No
Details of use of the vehicle:
Courier use - Within 100 miles radius
Courier use - Within all of UK
Carriage of own goods-Unlimited radius from base
Carriage of own goods-Within 100 mile radius from base
Carriage of passengers
Haulage-within 100 mile radius from base
Haulage-unlimited radius from base
Not used for business (social, domestic & pleasure use)
Cover
Type of cover required:
Comprehensive
Third Party, Fire & Theft
Third Party Only
Total excess amount:(lower premiums for a higher excess)
£250
£500
£750
£1,000
Number of Years No Claims Bonus:
Please Select
0 Years
1 Years
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
15+ Years
Type of policy No Claims Bonus earned under:
Commercial Vehicle
Courier
Private Car
Motorcycle
Other
Not Applicable
Is Protected No Claims Bonus required?(only available if you have at least 4 years no claims bonus) Yes No
Further Details
Do you, or any of the drivers have any non-motoring convictions? Yes No
If yes, please provide details:(i.e. name of driver, date(s) of conviction(s), reason for conviction(s) amount of any fine(s) (if applicable), length of custodial sentence (if applicable), etc.)
Have you, or any other driver ever had any insurance refused/cancelled or special terms imposed within the past 5 years? Yes No
If yes, please provide details:(i.e. name of driver, date insurance refused/cancelled/special terms, reason for insurance refused/cancelled/special terms, etc.)
Have you, or any other driver ever been declared bankrupt, insolvent, or ever had any IVA's, CCJ's or Sheriff Decrees? Yes No
If yes, please provide details:(i.e. name of driver, date of bankruptcy/insolvency/IVA/CCJ, date bankruptcy/insolvency/IVA/CCJ discharged or settled, amount of bankruptcy/insolvency/IVA/CCJ, reason for bankruptcy/insolvency/IVA/CCJ, etc.)
Driving Details
Who will drive the vehicle?
Proposer Only
Proposer & 1 Named Driver
Proposer & 2 Named Drivers
Proposer & 3 Named Drivers
Any Driver Over 25
Any Driver
Proposer's / Main Driver's Details
Status:
Mr
Miss
Mrs
Ms
Dr
First name:
Surname:
Occupation:(please amend if different to 'Courier Driver')
Is this full-time or part-time work?
Full-time
Part-time
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
- - - Please Select - - -
Common Law Married
Divorced
Married
Seperated
Single
Widowed
Number of years resident in the UK?
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Please Select
Provisional UK
Full UK
EU Provisional
EU Full
HGV Class 1
HGV Class 2
HGV Class 3
International
Number of years licence held: years
Driving licence number (if available) :(this may help you obtain a more competitive premium)
Does the proposer also own a car? Yes No
If yes, please state number of years no claims discount on the car policy:
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
9+ years
Please advise if there have been any accidents or claims in the last five years (regardless of fault )? Yes No
If yes, please provide details:
Please advise if there have been any motoring convictions or offences? Yes No
If yes, please provide details:
Please advise if there are any medical conditions or disabilities? Yes No
If yes, please provide details:
Additional Drivers (max. 3 additional drivers)
Do you wish to add another driver? Yes No
Details Of Driver 2
Status:
Mr
Miss
Mrs
Ms
Dr
First Name:
Surname:
Their Primary Occupation:(please amend if different to 'Courier Driver')
Their Employer's Business:(please amend if different to 'Courier Service')
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
Single
Married
Common Law Married
Divorced
Seperated
How long have they lived in the UK:
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Full UK
Provisional UK
EU Provisional
EU Full
HGV Class 1
HGV Class 2
HGV Class 3
International
How long have they held their licence? years
Driving licence number (if available) :(this may help you obtain a more competitive premium)
Relationship to Proposer:
Brother or Sister
Business Partner
Common-Law Spouse
Daughter or Son
Daughter-In-Law/Son-In-Law
Director
Family
Lodger
Not Applicable
Parent
Partner - Civil
Proposer's Employee
Proposer's Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Has this driver had any accidents or claims in the last five years? (regardless of fault ) Yes No
If yes, please provide details:
Has this driver ever been convicted of any motor offences? Yes No
If yes, please provide details:
Does this driver have any medical conditions or disabilities? Yes No
If yes, please provide details:
Additional Drivers
Do you wish to add another driver? Yes No
Details Of Driver 3
Status:
Mr
Miss
Mrs
Ms
Dr
First Name:
Surname:
Their Primary Occupation:(please amend if different to 'Courier Driver')
Their Employer's Business:(please amend if different to 'Courier Service')
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
Single
Married
Common Law Married
Divorced
Seperated
How long have they lived in the UK:
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Full UK
Provisional UK
EU Provisional
EU Full
HGV Class 1
HGV Class 2
HGV Class 3
International
How long have they held their licence? years
Driving licence number (if available) :(this may help you obtain a more competitive premium)
Relationship to Proposer:
Brother or Sister
Business Partner
Common-Law Spouse
Daughter or Son
Daughter-In-Law/Son-In-Law
Director
Family
Lodger
Not Applicable
Parent
Partner - Civil
Proposer's Employee
Proposer's Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Has this driver had any accidents or claims in the last five years? (regardless of fault ) Yes No
If yes, please provide details:
Has this driver ever been convicted of any motor offence? Yes No
If yes, please provide details:
Does this driver have any medical conditions or disabilities? Yes No
If yes, please provide details:
Additional Drivers
Do you wish to add another driver? Yes No
Details Of Driver 4
Status:
Mr
Miss
Mrs
Ms
Dr
First Name:
Surname:
Their Primary Occupation:(please amend if different to 'Courier Driver')
Their Employer's Business:(please amend if different to 'Courier Service')
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
Single
Married
Common Law Married
Divorced
Seperated
How long have they lived in the UK:
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Full UK
Provisional UK
EU Provisional
EU Full
HGV Class 1
HGV Class 2
HGV Class 3
International
How long have they held their licence? years
Driving licence number (if available) :(this may help you obtain a more competitive premium)
Relationship to Proposer:
Brother or Sister
Business Partner
Common-Law Spouse
Daughter or Son
Daughter-In-Law/Son-In-Law
Director
Family
Lodger
Not Applicable
Parent
Partner - Civil
Proposer's Employee
Proposer's Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Has this driver had any accidents or claims in the last five years? (regardless of fault ) Yes No
If yes, please provide details:
Has this driver ever been convicted of any motor offence? Yes No
If yes, please provide details:
Does this driver have any medical conditions or disabilities? Yes No
If yes, please provide details:
Goods In Transit Cover
Is Goods In Transit cover required? Yes No
Goods In Transit sum insured (e.g. £10,000) :
Public Liability Insurance
Is Public Liability cover required? Yes No
Public Liability limit of indemnity:
£1,000,000
£2,000,000
£5,000,000
£10,000,000
Legal Expenses Cover
Is Legal Expenses cover required?(£50,000 standard limit) Yes No
Additional Information / Material Facts
Details of any additional information or material facts that may affect the acceptance of this insurance:
Under the legal principle of Utmost Good Faith, you are required to disclose all material facts which could affect acceptance of this insurance quotation. Failure to disclose a material fact could invalidate any future claims. By submitting this quotation you are confirming that there are no other material facts to disclose other than those shown above.