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COMMERCIAL VEHICLE QUOTATION FORM
*
Mandatory information
Please leave blank:
YOUR DETAILS
Title:
Mr
Mrs
Miss
Dr
First Name:
Surname:
Email Address:
Contact tel no:
Company Name:
Address:
Postcode:
VEHICLE DETAILS
Make / Model. Please specify the Exact Model
Make / Model:
Body Type:
Select
Van
Pick Up
Tipper
Truck
Lorry-Rigid
Lorry-Articulated
Special Type
No. Seats:
Select
2
3
5
More
Engine Size:
Registration No:
Transmission Type:
Manual
Auto
Imported Vehicle:
No
Yes
Right Hand Drive:
Yes
No
Where will vehicle be kept at home?
Garage
Driveway
Road
Other
Do you have access to another vehicle?
Yes
No
If yes how many?
Date of Manufacture:
Date of Purchase:
Annual Mileage:
Any security details:
None
Category 1
Category 2
Tracker
Manufacturer Standard Fit
List any modifications:
Gross Vehicle Weight (GVW):
INSURANCE COVER REQUIRED
Cover:
Comprehensive
TPF&T
TPO
Use:
Own goods only
Haulage
Courier Use
Other
PROPOSER DETAILS
Drivers:
Insured Only
Insured & Spouse
Any Driver 25+
Named
Date of Birth:
Date Test Passed:
License Type:
Full UK
Provisional
Full EEC International
Other
Other License:
Status:
Married
Single
Divorced
Widowed
Common Law
Other
Other Status:
Employment Status:
Employed
Self Employed
UnEmployed
Occupation:
Home:
Own
Rent
Other
Other:
Smoker:
Yes
No
NUMBER OF ADDITIONAL DRIVERS
Number:
0
1
2
3
4
NCB AVAILABLE TO USE
No of years NCB:
Expiry of current policy
Exp Month:
Select
January
February
March
April
May
June
July
August
September
October
November
December
Exp Year:
Select
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
UNDERWRITING AND INSURANCE HISTORY
Refusal:
No
Yes
EVER HAD INSURANCE REFUSED, DECLINED OR TERMS IMPOSED
Premium:
No
Yes
EVER HAD AN INCREASED PREMIUM APPLIED
Convictions D&D:
No
Yes
HAD/HAVE AND CONVICTIONS FOR DRINK OR DRUGS
Convictions Criminal:
No
Yes
HAD/HAVE A CRIMINAL CONVICTION SPENT OR PENDING UNDER THE REHABILITATION OF OFFENDERS ACT 1974
ACCIDENT HISTORY
Last 5 Years (Fault or Non Fault)
Have you (or any named drivers) been involved in any Accidents regardless of blame in the last 5 years?
Convictions:
No
Yes
Convictions Details:
CONVICTION HISTORY
Last 5 Years
Have you (or any named drivers) had any convictions
in the last 5 years?
Convictions:
No
Yes
DECLARATION
I DECLARE THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL THE ANSWERS ARE TRUE AND NO MATERIAL FACTS HAVE BEEN OMMITTED. I AGREE THAT IF ANY ANSWERS ARE INCORRECT THEN THE QUOTATION GIVEN MAY ALSO BE INCORRECT AND IF A POLICY IS TAKEN OUT FROM THIS QUOTATION THEN THE COVER MAY BE INVALID AND MAY RESULT IN A CLAIM NOT BEING PAID BY THE INSURER.
Confirm :
I Agree
I Disagree
For the purposes of the Data Protection Act 1998 the data controller in relation to any personal data you supply is Crisp Specialist Risks Ltd.
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