Car Test From

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How did you hear about us?

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About You

Title

Name

First

Middle

Last

Date of Birth

Marital Status

Have you been a UK resident since birth?

If No, when did you start continuously living in the UK?

This needs to be the date from which you’ve lived here as a resident up to now.

Address (House Number, Street)

Phone

What is your employment status?

If Employed/Self Employed, What is your main occupation?

If Employed/Self Employed, What industry is this occupation in?

Type of course

Home owner

Any children under 16

How many children under 16 do you have?

Contact Details

Phone

Driving History

What type of licence does the driver currently have?

Please enter your driving licence number

Some company may offer a discount if you enter your driving licence number.

Period licence held for

Where does the driving Licence come from?

What date was licence obtained?

Any driver insurance declined, cancelled, voided or special terms imposed

what is the name of the insurance company?

Reason for decline or cancellation

Are you currently insured?

What Company are you currently insured with?

How much is your current insurance?

Do you have any non-motoring criminal convictions?

Motor Accidents

Have you had any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years?

Motor Accident or Claim Details 1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Add another motor accident *

Motor Accident or Claim Details 2

Type (2)

Date (2)

Damage (2)

Cost(£) - if known (2)

Fault (2)

Any Injuries (2)

Add another motor accident

Motor Accident or Claim Details 3

Date (3)

Type (3)

Damage (3)

Cost(£) - if known (3)

Fault (3)

Any Injuries (3)

Add another motor accident

Motor Accident or Claim Details 4

Type (4)

Date (4)

Damage (4)

Cost(£) - if known (4)

Fault (4)

Any Injuries (4)

Add another motor accident

Motor Accident or Claim Details 5

Type (5)

Date (5)

Damage (5)

Cost(£) - if known (5)

Fault (5)

Any Injuries (5)

Motor Convictions

Have you had any motor convictions, fixed penalties or disqualifications in the last 5 years?

Motor Conviction, Fixed Penalty or Disqualification Details 1

Conviction Code

Date

Points

Fine(£) - if any

Ban (months) - if any

Add another motor convictions

Motor Conviction, Fixed Penalty or Disqualification Details 2

Conviction Code (2)

Date (2)

Points (2)

Fine(£) - if any (2)

Ban (months) - if any (2)

Add another motor convictions

Motor Conviction, Fixed Penalty or Disqualification Details 3

Conviction Code (3)

Date (3)

Points (3)

Fine(£) - if any (3)

Ban (months) - if any (3)

Add another motor convictions

Motor Conviction, Fixed Penalty or Disqualification Details 4

Conviction Code (4)

Date (4)

Points (4)

Fine(£) - if any (4)

Ban (months) - if any (4)

Add another motor convictions

Motor Conviction, Fixed Penalty or Disqualification Details 5

Conviction Code (5)

Date (5)

Points (5)

Fine(£) - if any (5)

Ban (months) - if any (5)

Vehicle Details

Vehicle Registration *

Date of purchase

What is the current value of the car?

Who is the car registered to?

Who is the owner of the car?

How many miles do you drive per year?

Annual mileage refers to the number of miles you drive each year

Use of Vehicle

Type of Cover

Any no claims discount

Would you like to protect your NCD?

When would you like the policy to start?

How do you normally pay for insurance?

Additional Drivers

Would you like to add an additional driver?

Additional Driver (1) Details

Relationship to Proposer

Title

Name

First

Middle

Last

Date of Birth

Marital Status

Have you been a UK resident since birth?

If No, when did you start continuously living in the UK?

This needs to be the date from which you’ve lived here as a resident up to now.

What is your employment status?

If Employed/Self Employed, What is your main occupation?

If Employed/Self Employed, What industry is this occupation in?

Type of course

What type of licence does the driver currently have?

Please enter your driving licence number

Some company may offer a discount if you enter your driving licence number.

Where does the driving Licence come from?

Period licence held for

What date was licence obtained?

Has Additional Driver (1) had any accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years?

Motor Accident or Claim Details 1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Add another motor accident

Motor Accident or Claim Details 2

Type (2)

Date (2)

Damage (2)

Cost(£) - if known (2)

Fault (2)

Any Injuries (2)

Add another motor accident

Motor Accident or Claim Details 3

Type (3)

Date (3)

Damage (3)

Cost(£) - if known (3)

Fault (3)

Any Injuries (3)

Has Additional Driver (1) had any motor convictions, fixed penalties or disqualifications in the last 5 years?

Conviction, Penalty or Disqualification Details 1

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban (months) - if any

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 2

Conviction Code (2)

Date of Conviction (2)

Points (2)

Fine(£) - if any (2)

Ban (months) - if any (2)

Add another Conviction, Penalty or Disqualification *

Conviction, Penalty or Disqualification Details 3

Conviction Code (3)

Date of Conviction (3)

Points (3)

Fine(£) - if any (3)

Ban (months) - if any (3)

Would you like to add a second driver?

Additional Driver (2) Details

Relationship to Proposer

Title

Name

First

Middle

Last

Date of Birth

Marital Status

Have you been a UK resident since birth?

If No, when did you start continuously living in the UK?

This needs to be the date from which you’ve lived here as a resident up to now.

What is your employment status?

If Employed/Self Employed, What is your main occupation?

If Employed/Self Employed, What industry is this occupation in?

Type of course

What type of licence does the driver currently have?

Please enter your driving licence number

Some company may offer a discount if you enter your driving licence number.

Where does the driving Licence come from?

Period licence held for

What date was licence obtained?

Has Additional Driver (2) had any accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years? *

Motor Accident or Claim Details 1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Add another motor accident

Motor Accident or Claim Details 2

Type (2)

Date (2)

Damage (2)

Cost(£) - if known (2)

Fault (2)

Any Injuries (2)

Add another motor accident

Motor Accident or Claim Details 3

Type (3)

Date (3)

Damage (3)

Cost(£) - if known (3)

Fault (3)

Any Injuries (3)

Has Additional Driver (2) had any motor convictions, fixed penalties or disqualifications in the last 5 years?

Conviction, Penalty or Disqualification Details 1

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban (months) - if any

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 2

Conviction Code (2)

Date of Conviction (2)

Points (2)

Fine(£) - if any (2)

Ban (months) - if any (2)

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 3

Conviction Code (3)

Date of Conviction (3)

Points (3)

Fine(£) - if any (3)

Ban (months) - if any (3)

Would you like to add a third driver? *

Additional Driver (3) Details

Relationship to Proposer

Title

Name

First

Middle

Last

Date of Birth

Marital Status

Have you been a UK resident since birth?

If No, when did you start continuously living in the UK?

This needs to be the date from which you’ve lived here as a resident up to now.

What is your employment status?

If Employed/Self Employed, What is your main occupation?

If Employed/Self Employed, What industry is this occupation in?

Type of course

What type of licence does the driver currently have?

Please enter your driving licence number

Some company may offer a discount if you enter your driving licence number.

Where does the driving Licence come from?

Period licence held for

What date was licence obtained?

Has Additional Driver (3) had any accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years?

Motor Accident or Claim Details 1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Add another motor accident

Motor Accident or Claim Details 2

Type (2)

Date (2)

Damage (2)

Cost(£) - if known (2)

Fault (2)

Any Injuries (2)

Add another motor accident

Motor Accident or Claim Details 3

Type (3)

Date (3)

Damage (3)

Cost(£) - if known (3)

Fault (3)

Any Injuries (3)

Has Additional Driver (3) had any motor convictions, fixed penalties or disqualifications in the last 5 years?

Conviction, Penalty or Disqualification Details

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban (months) - if any

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 2

Conviction Code (2)

Date of Conviction (2)

Points (2)

Fine(£) - if any (2)

Ban (months) - if any (2)

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 3

Conviction Code (3)

Date of Conviction (3)

Points (3)

Fine(£) - if any (3)

Ban (months) - if any (3)

Would you like to add a fourth driver?

Additional Driver (4) Details

Relationship to Proposer

Title

Name

First

Middle

Last

Date of Birth

Marital Status

Have you been a UK resident since birth?

If No, when did you start continuously living in the UK?

This needs to be the date from which you’ve lived here as a resident up to now.

What is your employment status?

If Employed/Self Employed, What is your main occupation?

If Employed/Self Employed, What industry is this occupation in?

Type of course

What type of licence does the driver currently have?

Please enter your driving licence number

Some company may offer a discount if you enter your driving licence number.

Where does the driving Licence come from?

Period licence held for

What date was licence obtained?

Has Additional Driver (4) had any accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years?

Motor Accident or Claim Details 1

Type

Date

Damage

Cost(£) - if known

Fault

Any Injuries

Add another motor accident

Motor Accident or Claim Details 2

Type (2)

Date (2)

Damage (2)

Cost(£) - if known (2)

Fault (2)

Any Injuries (2)

Add another motor accident

Motor Accident or Claim Details 3

Type (3)

Date (3)

Damage (3)

Cost(£) - if known (3)

Fault (3)

Any Injuries (3)

Has Additional Driver (4) had any motor convictions, fixed penalties or disqualifications in the last 5 years?

Conviction, Penalty or Disqualification Details

Conviction Code

Date of Conviction

Points

Fine(£) - if any

Ban (months) - if any

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 2

Conviction Code (2)

Date of Conviction (2)

Points (2)

Fine(£) - if any (2)

Ban (months) - if any (2)

Add another Conviction, Penalty or Disqualification

Conviction, Penalty or Disqualification Details 3

Conviction Code (3)

Date of Conviction (3)

Points (3)

Fine(£) - if any (3)

Ban (months) - if any (3)

Additional comments

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