Tel: 01623 641 386     
Fleet Insurance Quotes
 
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Fleet Insurance Quote Form

For UK Customers Only

Please insert your details below and one of our commercial advisers will contact you shortly with a fleet insurance quotation. This form is designed for quotes for Fleet Insurance for a minimum of 5 vehicles only.

Alternatively, if you wish to send a list/schedule of your vehicles, drivers and current 3 year claims experience form, please either email mail@midlandsinsurance.co.uk or fax 01623 429991.

If you have any problems with completing this form, please phone us on 01623 641 386 for assistance.

Personal/Company Details

Proposers Full Name(s):
(enter sole trader's name or all partner's names if a partnership)
Limited Company Name (if applicable):
Trading Name:
Trading Status:
Business/Trade Description:
Business Address:
Postcode:
Daytime Telephone Number:
Mobile Telephone Number:
E-Mail Address:

General Information

Have you, or any other partner or director ever been
convicted of any offences, been declared bankrupt/
insolvent or had any insurance refused or cancelled?
Yes     No
If yes, please provide details:
(e.g. type of incident, date(s), amounts of
bankruptcy, fines, custodial sentence, etc.)

Insurance Details
Cover required: Comprehensive
Third Party Fire & Theft
Third Party Only

Use required:
(Please tick all those applicable)
Social, Domestic & Pleasure ex. Commuting
Social, Domestic & Pleasure inc. Commuting
Business Use
Haulage
Self-Drive Hire
Public Hire
Private Hire
Other (please describe):

Do you require cover for foreign use?Yes     No help
If yes, please state type of territories and the
frequency of work spent at the location(s):

Drivers
Please confirm the driving restriction required: Any Driver (regardless of age)
Any Driver Over 21
Any Driver Over 25

Please send a list of any drivers aged under 25 or over 65 or with less than 2 years full UK licence,
details of drivers with claims in the last 3 years,
drivers with driving convictions involving a ban as well as other convictions in the last 5 years
or drivers with any medical conditions
by either email to mail@midlandsinsurance.co.uk or by fax to 01623 429991.

Trading Experience
How many years has your business been trading?

Fleet Vehicles to be Insured

Details of Vehicles In Fleet
Number of vehicles in the fleet:
Types of vehicles in fleet:
(Please tick all those applicable)
Cars
Vans up to 3.5 tonnes GVW
Lorries up to 7.5 tonnes GVW
Lorries over 7.5 tonnes GVW
Minibus/Coaches

Details of Vehicles to be Insured

Please send a list or your schedule of vehicles by either
email to mail@midlandsinsurance.co.uk or by fax to 01623 429991.

Additional Information / Material Facts
Details of any additional information or material
facts that may affect the rating 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.
Details Of Current / Previous Policies

Current Annual Premium:
This may help us to get you a better quote
Current/Previous Insurer:
Renewal Date (if applicable): (dd/mm/yyyy)

Claims Experience

Please send your current insurers 3 years claims experience form by either
email to mail@midlandsinsurance.co.uk or by fax to 01623 429991.

Request Quotation

Disclosure
Please ensure that all the information you have provided is correct, then press the Request Fleet Insurance Quote button and we will contact you shortly with a quotation.