Title: Mr Mrs Miss Ms Sir Dr
Full Name:
Date of Birth:
email:
Mobile Number:
Daytime Contact Number:
House / Building Number:
Postcode:
Motor Trade Activities
Sales Mechanical Vehicle Servicing Body Repairs Tyre Sales/Fitting Valeting
Vehicle Recovery Salvage and Breaking Other
Cover for road risks only. Yes No
Type of Premises home Locked Compound Forecourt Garage Workshop
Cover Required Comprehensive Third party, fire, theft Third party only
Limit to Indemnity £5,000 £7,500 £10,000 £15,000 £20,000 Other
Date your business commenced:
Required Policy Start Date
Motor Trade No Claims Discount 0 1 2 3 4 5 6 7 8 9 10+ Years
Number of drivers to be covered: 1 2 3 4 5 6 7 8 9 10 10+
Number of employees you employ 0 1 2 3 4 5 6 7 8 9 10 10+
How long have you held your drivers licence? 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+ Years
Do you have any driving convictions Yes No
If 'Yes', please specify