Cover type *

Vehicle Specifics

Year of Manufacturer

Make

Model

Variant 🛈

Registration

Vehicle use

Does the vehicle have hail damage?

Is the Vehicle financed

Finance Company

Drivers

First Name

Last Name *

Gender

Date of Birth of Oldest Insured * +

Year licence obtained

Number of criminal convictions in the past 3 years

Claim in the last 5 years

Claim Details

Do you wish to Add Additional Driver to avoid additional excesses

Additional Drivers First Name Surname Date of Birth Gender Year licence obtained Number of criminal convictions in the past 3 years Has there been any claims and/or licence suspensions in the past 3 years? *

Cover

Vehicle sum insured (excluding non-standard accessories and modifications)

Sum Insured Option

Agreed Value Cover Required

Motor Insurance Excess Option

Include Cover Options

Hire car during repairs

Windscreen excess waiver

Do wish to include any of the following cover options?

Does the vehicle have any of the following?

Specialised Paint

Turbo / Supercharger

Nitro / Hydrogen Fuel

Roll Bar / Roll Cage / Racing Harness

Does the vehicle have any non-standard accessories that will be included within the cover?

Non Standard Accessories
Please supply a description of Non Standard Accessories to be Insured and the Sum Insured

Overnight parking address

Street

City

PostCode

Currently Insured

Current Insurer

Current Premium

Underwriting Acceptance Criteria

Is the vehicle either
• unregistered or have any existing damage (excluding minor scratches, wear and tear or hail damage) or
• used for
• Driver Education
• Racing or Sporting Events
• Courier or Delivery Services
• Or used as a
• Hire Car
• Courtesy Car
• Taxi or
• Removalist vehicle

Or

Have you been declined insurance in the past 12 months

Or

Has your license been suspended or resticted in the past 5 years?

Underwriters consideration & Comments (please provide details)

Declaration: I/WE HEREBY DECLARE AND WARRANT that the answers given above are in every respect true and correct, and that I/We have not withheld any information within My/Our knowledge likely to affect the decision of the Company as to My/Our eligibility for insurance. This request and declaration shall be the basis of the quote request. *

Contact Info

Phone *

Email *

Best time to Call

Additional Information