Motor Insurance

Disclaimer

Main Driver will be considered the Registered Keeper and Owner, if this is not correct please note this in the additional information Box below. Furthermore we are presuming that each driver has NO medical Conditions, NO non-Motoring Convictions, Never Been declined Insurance or had an insurance Cancelled. (If this is not the case, please note this in the additional Information Section).

We will provide Quotes on all three Basis, Comprehensive, Third Part Fire & Theft and Third Party Only. Both NCD protect and not protected.

IF YOU PREFER TO TALK TO US PLEASE CALL US ON 01234 353168 OR FILL UP AS MUCH AS YOU CAN & WE WILL CALL YOU BACK

Personal Details

Full Name
Date of Birth
Renewals or Start Date
House Number & Postcode (e.g. 1, MK40 1AB)
Contact Telephone
Email Address
Your Occupation?
Home Owner?	yes no
How many cars do you own?

Business Use Vehicles Only

Type of Business?

Insurance Details

Type of Insurance?
Type of Licence Held?
Number of Years Licence Held?
Claims in last five Years? (If yes fill in Box Below)	Date of Claim? Type of Claim? (Accident. etc) Fault or Non Fault? NCD Effected? Costs of Injury if any? Costs Incurred?
	Date of Claim? Type of Claim? (Accident. etc) Fault or Non Fault? NCD Effected? Costs of Injury if any? Costs Incurred?
Convictions in the last Five year? (If yes fill in table below)	Date of Convictions? Points Disqualification Months? Sample Reading Sample Type (Blood, Breath)
	Date of Convictions? Points Disqualification Months? Sample Reading Sample Type (Blood, Breath)
Taxis NCD (yrs)

Vehicle Details?

Vehicle’s Make
Model (Inc Engine Size)
Registration
Year of Registration
Purchase Date?
Any Modifications or Security (Please Specify)
Years of No Claim Bonus?
Type of Bonus?
* Beside this vehicle do you have any more No Claims Bonus on other vehicles, please specify number of years for each vehicle.	Vehicle 2: NCD years Vehicle 3 NCD Years (This info can help reduce your premium)
Vehicle Use?
Other (Please Specify)
Value of Vehicle (£)?
Annual Mileage (Ave 5000-8000 miles)
Additional Drivers please fill the	Date of Convictions? Name: Relationship to Main Driver: Occupation: Convictions Please Specify: Claims Please Specify Type of License: How long held License: Any Bonus
	Date of Convictions? Name: Relationship to Main Driver: Occupation: Convictions Please Specify: Claims Please Specify Type of License: How long held License: Any Bonus
Additional Information & Questions

Gill Insurance & Finance Consultants Ltd n 78-80 Tavistock Street n Bedford n MK40 2RP Tel No. 01234 353168 Fax No. 01234 346304

Gill insurance and Finance Consultants Ltd is Authorised and Regulated by the Financial Service Authority
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