Proposers/Company Details
Business / Trade use of the commercial vehicle:(e.g. plumber, builder, etc.)
Please state the purpose of use for the vehicle:(e.g. collection of goods from wholesaler, carry tools & materials, etc.)
Business Address:
Business Postcode:
Daytime Telephone No.
E-mail Address:
Date Cover Required: (dd/mm/yyyy)
Commercial Vehicle Details
Type/Category of Commercial Vehicle:
Box Van
Breakdown/Recovery
Caravanette
Coach
Crane, Lorry Mounted
Ice Cream Van
Light Van
Lorry-Articulated
Lorry-Rigid Body
Low Loader
Luton Van
Minibus
Mobile Shop
Motor Caravan
Pick-Up
Refrigerated
Security Vehicle
Skip Carrier
Tanker-Articulated
Tanker-Rigid Body
Tipper
Tractor
Truck-Curtainside
Truck-Dropside
Truck-Flat Bed
Van
Vehicle Transporter
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 Made:
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:
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
Fuel type:
Please Select
Petrol
Diesel
Gas
Steam
Postcode where vehicle is kept overnight:(if different from the 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
Type of goods carried:
Non-hazardous goods
Toxic/corrosive/inflammable
Radioactive materials
Other
Is the vehicle modified? Yes No
If yes, please provide details of the modifications:
Is the vehicle Left Hand Drive? Yes No
Details of use of the vehicle:(if other than carriage of own goods)
Agricultural Use
Airside Use
Ambulance
Carriage of own goods-Unlimited radius from base
Carriage of own goods-Within 100 mile radius from base
Carriage of passengers
Driving tuition/official test
Haulage-within 100 mile radius from base
Haulage-unlimited radius from base
Hire & reward / Courier use
Not used for business (social, domestic & pleasure use)
Tree felling/haulage of felled trees
Articulated Vehicles Only
Is a trailer or container attached to the vehicle: Yes No
If yes, please state the value (£s) :
Cover & Driving Details
Cover
Type of cover required:
Comprehensive
Third Party, Fire & Theft
Third Party Only
Total excess amount:(lower premiums for a higher excess)
£100
£250
£350
£500
£750
Number of years No Claims Bonus:
Please Select
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
9+ 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
Any non-motoring convictions? Yes No
If yes, please provide details:(name of person, date(s) of convictions, any fine, any custodial sentence, etc.)
Driving Details
Who will drive the vehicle?
- - - - - - Please Select - - - - - -
Proposer Only
Proposer & 1 Named Driver
Proposer & 2 Named Drivers
Any Driver Over 25
Any Driver
Policy Type
Is the policy to be in a company name? Yes No
If yes, please confirm the name of the company:
Proposers / Main Drivers Details
Proposers / Main Drivers Details
Status:
Mr
Miss
Mrs
Ms
Dr
First name:
Surname:
Occupation:
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
EEC Provisional
EEC Full
HGV Class 1
HGV Class 2
HGV Class 3
International
Number of years licence held:
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 disabilities? Yes No
If yes, please provide details:
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:
Their Employers Business:
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
EEC Provisional
EEC Full
HGV Class 1
HGV Class 2
HGV Class 3
International
How long have they held their licence? years
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
Proposers Employee
Proposers 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 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:
Their Employers Business:
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
EEC Provisional
EEC Full
HGV Class 1
HGV Class 2
HGV Class 3
International
How long have they held their licence? years
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
Proposers Employee
Proposers 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 disabilities? Yes No
If yes, please provide details:
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