Your
Policy details :
Title
Mr
Mrs
Miss
Ms
Dr
Sir
Prof
Reverend
Councillor
Dame
Dean
Judge
Lady
Lord
First
name
Surname
Reference number
Postcode
(xxxx xxx)
Email address
What is your mobile
phone number?
What is your daytime
phone number?
New
driver details : Title
Mr
Mrs
Miss
Ms
Dr
Sir
Prof
Reverend
Councillor
Dame
Dean
Judge
Lady
Lord
Forename
Surname
Address
Age
Date of birth
Precise occupation, profession
or business including part time. If unemployed state
previous employment.
Number
of years of continuous residence in the UK.
State
type of UK drivers licence
Full UK
Provisional
How
long have you regularly driven cars in the UK ?
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years or more
State
date on which you passed the UK car driving test
(dd/mm/yyyy)
If
provisional licence held state the number of attempts
to pass the UK driving test
1
2
3
4
5
6
7
8
9
10
Have
you ever been disqualified from driving or in the
past five years been convicted of any offence connected
with a motor vehicle or is there any police enquiry
or prosecution pending ?
No
Yes
State
offence, date, penalty and period of suspension
Give
details of any accident, claim or loss during the
past three years whether to blame or not. State date,
circumstances, costs or estimated costs
Give
details of any loss, loss of use or defect of limb,
eye, vision or hearing and any heart disorder, diabetes,
epilepsy, fits of any kind, mental condition or other
physical disability.
Has
any motor insurance ever been declined, cancelled
or refused or has an increased premium been charged
or any special terms been imposed
If changes are
acceptable when would you like cover to commence from
?
(dd/dd/yyyy)
Any other details or amendments ?
