Company Name:

Number of Years Trading: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 +

Nature of business:

Building Name/ Number:

Postcode:

Contact Name:

Contact Telephone Number:

Mobile Number:

e-mail:

Preferred Contact Method: Contact Number Mobile Number e-mail

Do you currently have a Fleet Policy: Yes No

Policy Commencement Date :

Current Insurer:

Current Premium (£):

Number of Vehicles: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 +

Cover Required: Comprehensive Third Party Fire and Theft Third Party Only

Driving Requirements: Any Driver Any Driver over 21 yrs Any Driver over 25 yrs

Number of drivers under 25 years old: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 +

Has anyone on this policy obtained any current
Motoring Convictions on their licence: Yes No

If there are current convictions, please give details: