Private Car - Client Details and General Information

Full Client Name
Address
Proposer type
Company name
Title
First name
Surname
Correspondence address
Homeowner
Voluntary excess requested (£)
Allow insurers to use publicly available data, eg. credit checks (searches appear on credit reports)

Period of Insurance

Renewal Date

Scope of Cover

Sections covered by this Questionnaire

The following risks are covered in this questionnaire:

· Drivers

· Vehicle

Sections not covered by this Questionnaire

If cover for the following risks is required, please contact us and we will be delighted to send you an updated questionnaire.

· Driver

· Endorsements and Excesses

NullPrivate Car Risk Questionnaire Miss Hazel Westwood186203378MomentumPress House
Narborough Wood Park
Desford Road
Enderby
LE19 4XT4148582

Vehicle

Cover basis
Registration number
Vehicle make/model
Overnight parking postcode
Overnight parking
Valid drivers
Year first registered (yyyy)
Purchase date of vehicle
Value (£)
Vehicle body type
Number of seats
Vehicle annual private mileage
Vehicle annual business mileage
Security device
Security device type
Post-manufacture accessories value (£)
Security device fitter
Left or right hand drive
Modified
Type of modification
Modification due to medical condition
Vehicle registered keeper
Vehicle owner
Previously insured
Previous insurer
Previous payment method
Previous policy expiry date (if N/A, enter current date)
NCB years
Protected NCB requested
NCB type (If N/A, use Private Car Bonus)
Additional security device type
Additional security device fitter

Proposer Details

Main driver of any listed vehicle
Registration number
Frequent driver of any listed vehicle
Registration number
Excluded from driving any listed vehicle
Registration number
Class of use
Driver title
Driver first name
Driver surname
Driver date of birth
Years resident in UK
Driver gender
Driver marital status
Driver licence type
Driver licence valid from
Additional driving qualifications
Number of other vehicles driven
Driver owns other vehicles
Company car experience where the company car is no longer driven
Company car NCD years
Date company car use ended
Driver occupation
Driver type of business
Driver employment status
Full time
Driver has additional occupation
Driver additional occupation
Driver additional occupation type of business
Driver additional occupation employment status
Driver additional occupation full time employment
Medical condition notifiable to the DVLA
Have any of these conditions caused the driver's licence to be restricted
Cover previously refused
Previous convictions
Prosecution pending
Any claims with a previous insurer
Any non-motoring convictions

Claims History

Date of Claim / Driver Name / Description of Claim / Claim Amount / Reserve Amount

Additional Drivers

Relationship to proposer
Main driver of any listed vehicle
Registration number
Frequent driver of any listed vehicle
Registration number
Excluded from driving any listed vehicle
Registration number
Class of use
Driver title
Driver first name
Driver surname
Driver date of birth
Years resident in UK
Driver gender
Driver marital status
Driver licence type
Driver licence valid from
Additional driving qualifications
Number of other vehicles driven
Driver owns other vehicles
Company car experience where the company car is no longer driven
Company car NCD years
Date company car use ended
Driver occupation
Driver type of business
Driver employment status
Full time
Driver has additional occupation
Driver additional occupation
Driver additional occupation type of business
Driver additional occupation employment status
Driver additional occupation full time employment
Medical condition notifiable to the DVLA
Have any of these conditions caused the driver's licence to be restricted
Cover previously refused
Previous convictions
Prosecution pending
Any claims with a previous insurer
Any non-motoring convictions
Additional Info:

Additional Drivers

Office 71, 42 Triangle West, Clifton, Bristol BS8 1ES

t 0117 325 0560 f 0117 325 0561