Proposer's Full Name:
In whose name is the policy to be issued?
- - Please Select - -
Limited Company
Partnership
Sole Trader
Individual
Limited Company Name:(if policy is to be issued in a limited company name)
Business / Trade use of the commercial vehicle:(e.g. haulier, etc.)
Business Address:
Business Postcode:
Daytime Telephone No.
E-mail Address:
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes.
Cover Details
Date Cover Required / Renewal Date: (dd/mm/yyyy)
Current Annual Premium / Best Quotation: This may help us to get you a better quote
Name of Current / Previous Insurer: e.g. Aviva, AXA, Allianz, ERS, QBE, RSA, Zurich, etc.
Type/Category of Commercial Vehicle:
Box Van
Breakdown/Recovery
Caravanette
Coach
Crane, Lorry Mounted
Ice Cream Van
Light Van
Lorry-Articulated
Lorry-Rigid Body
Low Loader
Luton Van
Minibus
Mobile Shop
Motor Caravan
Pick-Up
Security Vehicle
Skip Carrier
Tanker-Articulated
Tanker-Rigid Body
Tipper
Tractor
Truck-Curtainside
Truck-Dropside
Truck-Flat Bed
Van
Vehicle Transporter
Other
Vehicle Make (i.e. Scania, Mercedes, Volvo, etc.) :
Vehicle Model (i.e. Topline, CF, Globetrotter, etc.) :
Vehicle Type (i.e. H123, 420, etc.) :
Gross Vehicle Weight (kg) :
Vehicle Engine Size (c.c.) :
Registration Number (if available) :
Year Made:
Value of the Vehicle (£'s) :
Additional Details
Who is the registered owner of the vehicle?
Proposer
Common Law Spouse
Company
Other
Spouse
Vehicle Leasing Co.
Who is the registered keeper of the vehicle?
Proposer
Common Law Spouse
Company
Other
Spouse
Vehicle Leasing Co.
Number of seats in the vehicle:
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16+
Fuel type:
Please Select
Petrol
Diesel
Gas
Steam
Postcode where vehicle is kept overnight:(if different from your business address)
Where is vehicle parked overnight?
- - - Please Select - - -
Car Park
Carport
Garaged
Locked Building
Locked Compound
Parked On Drive
Private Property
Public Road
Unlocked Building
Unlocked Compound
Annual mileage driven in the vehicle:
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
16,000
17,000
18,000
19,000
20,000
21,000
22,000
23,000
24,000
25,000
26,000
27,000
28,000
29,000
30,000
31,000
32,000
33,000
34,000
35,000
36,000
37,000
38,000
39,000
40,000
41,000
42,000
43,000
44,000
45,000
46,000
47,000
48,000
49,000
50,000
51,000
52,000
53,000
54,000
55,000
56,000
57,000
58,000
59,000
60,000
61,000
62,000
63,000
64,000
65,000
66,000
67,000
68,000
69,000
70,000
71,000
72,000
73,000
74,000
75,000
76,000
77,000
78,000
79,000
80,000
81,000
82,000
83,000
84,000
85,000
86,000
87,000
88,000
89,000
90,000
91,000
92,000
93,000
94,000
95,000
96,000
97,000
98,000
99,000
100,000
100,000+
Has the vehicle been imported? Yes No
If yes, please provide details of where the vehicle was imported from:
Details of immobiliser / alarm:
No Security
Manufacturer Fitted
Thatcham Category 1
Thatcham Category 2
Other Alarm or Immobiliser
Is the vehicle modified? Yes No
If yes, please provide details of the modifications:
Is the vehicle Left Hand Drive? Yes No
Is the vehicle refrigerated? Yes No
Is the vehicle fitted with a type approved digital tachograph?(Generally, vehicles 2006 onwards) Yes No
Trailers / Lifting Equipment
Does the vehicle/trailer(s) have lifting equipment? Yes No
If yes, type of trailer(s)?(e.g. flat, refrigerated, curtainside, tipping, etc.)
Is a trailer or container attached to the vehicle: Yes No
Please confirm the highest value trailer towed (£'s) :
Total number of trailers used?
Operators Licence Details
Please note that you must have a valid Operator's Licence in order to obtain a quotation. Please click here for details on who requires an Operator's Licence.
Do you have an Operators Licence? Yes No
Type of Operators Licence?
Not Applicable
International
National
Restricted
Operators licence base postcode:
Maximum distance of operation from base: miles
Operators licence number (if available) :
Use / Goods Carried
Details of use of the vehicle:(if other than Haulage)
Agricultural Use
Airside Use
Carriage of Own Goods-Unlimited radius from base
Carriage of Own Goods-Within 100 mile radius from base
Carriage of Passengers
Haulage-Unlimited radius from base
Haulage-Within 100 mile radius from base
Hire & Reward / Courier Use
Not used for business (Social, Domestic & Pleasure Use)
Tree felling/haulage of felled trees
Type of goods carried?
Main customers / main contracts?
Number of drops made daily?
Is delivery time critical? Yes No
Is same day delivery offered? Yes No
Are any hazardous goods carried? Yes No
If yes, please state hazardous goods class:
If yes, full load or part load? Full Load Part Load
If yes, frequency those goods are carried?(e.g. once a week, etc.)
Additional Details
How many years have you been 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
40+
years
How many commercial vehicles do you own?
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
40+
Is satellite navigation equipment used? Yes No
Cover
Type of cover required:
Comprehensive
Third Party, Fire & Theft
Third Party Only
Total excess amount:(lower premiums for a higher excess)
£100
£250
£350
£500
£750
Number of years No Claims Bonus:
Please Select
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
9+ years
Type of policy No Claims Bonus earned under:
Commercial Vehicle
Courier
Private Car
Motorcycle
Other
Not Applicable
Is Protected No Claims Bonus required?(only available if you have at least 4 years no claims bonus) Yes No
Further Details
Has the Proposer or any Person named on the policy ever been convicted of or charged with any offence (other than driving offences)? Yes No
If yes, please provide details:(name of person, date(s) of convictions, any fine, any custodial sentence, etc.)
Driving Details
Who will drive the vehicle?
- - - - - - Please Select - - - - - -
Proposer Only
Proposer & 1 Named Driver
Proposer & 2 Named Drivers
Any Driver Over 25
Any Driver
Proposer's / Main Drivers Details
Status:
Mr
Miss
Mrs
Ms
Dr
First name:
Surname:
Occupation:
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
- - - Please Select - - -
Common Law Married
Divorced
Married
Seperated
Single
Widowed
Number of years resident in the UK?
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Please Select
Provisional UK
Full UK
EEC Provisional
EEC Full
HGV Class 1 [C + E]
HGV Class 2 [C]
HGV Class 3 [C1]
International
Number of years licence held:
Does the proposer also own a car? Yes No
If yes, please state number of years no claims discount on the car policy:
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
9+ years
Please advise if there have been any accidents or claims in the last five years (regardless of fault )? Yes No
If yes, please provide details:
Please advise if there have been any motoring convictions or offences? Yes No
If yes, please provide details:
Please advise if there are any disabilities or medical conditions? Yes No
If yes, please provide details:
Additional Drivers
Do you wish to add another driver? Yes No
Details Of Driver 2
Status:
Mr
Miss
Mrs
Ms
Dr
First Name:
Surname:
Their Primary Occupation:
Their Employers Business:
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
Single
Married
Common Law Married
Divorced
Seperated
How long have they lived in the UK:
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Full UK
Provisional UK
EEC Provisional
EEC Full
HGV Class 1 [C + E]
HGV Class 2 [C]
HGV Class 3 [C1]
International
How long have they held their licence? years
Relationship to Proposer:
Brother or Sister
Business Partner
Common-Law Spouse
Daughter or Son
Daughter-In-Law/Son-In-Law
Director
Family
Lodger
Not Applicable
Parent
Partner - Civil
Proposers Employee
Proposers Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Has this driver had any accidents or claims in the last five years (regardless of fault )? Yes No
If yes, please provide details:
Has this driver ever been convicted of any motor offence? Yes No
If yes, please provide details:
Does this driver have any disabilities or medical conditions? Yes No
If yes, please provide details:
Additional Drivers
Do you wish to add another driver? Yes No
Details Of Driver 3
Status:
Mr
Miss
Mrs
Ms
Dr
First Name:
Surname:
Their Primary Occupation:
Their Employers Business:
Employment status:
Co. Director
Employed
Other
Retired
Self-Employed
Unemployed
Date of birth: (dd/mm/yyyy)
Driving status:
Main Driver
Frequent
Casual
Non-Driving
Marital status:
Single
Married
Common Law Married
Divorced
Seperated
How long have they lived in the UK:
Since Birth
0 years
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
20+ years
Type of licence:
Full UK
Provisional UK
EEC Provisional
EEC Full
HGV Class 1 [C + E]
HGV Class 2 [C]
HGV Class 3 [C1]
International
How long have they held their licence? years
Relationship to Proposer:
Brother or Sister
Business Partner
Common-Law Spouse
Daughter or Son
Daughter-In-Law/Son-In-Law
Director
Family
Lodger
Not Applicable
Parent
Partner - Civil
Proposers Employee
Proposers Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Has this driver had any accidents or claims in the last five years (regardless of fault )? Yes No
If yes, please provide details:
Has this driver ever been convicted of any motor offence? Yes No
If yes, please provide details:
Does this driver have any disabilities or medical conditions? Yes No
If yes, please provide details: