Proposer's Full Name(s):(enter sole trader's name or all partner's names if a partnership)
Contact Name:(if different to proposer's name)
Limited Company Name:(if operating as a limited company)
Trading Name:(if different to the above)
Trading Status:
- - - - - - - Please Select - - - - - -
Sole Trader
Partnership
Limited Company
Limited Liability Partnership (LLP)
Unincorporated Association
Business Description / Activities:
Business Address:
Business Postcode:
Daytime Telephone Number:
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.
General Details
Have you, or any other partner or director ever been convicted or charged (but not yet tried) with any criminal offences? Yes No
If yes, please provide details:(e.g. type of offence(s) length of custodial sentence, date of offence(s) etc.)
Have you, or any other partner or director ever been declared bankrupt/insolvent or subject to any County Court Judgements (CCJ's)/Sheriff Decrees or IVA's? Yes No
If yes, please provide details:(e.g. amount(s) of bankruptcy/insolvency/CCJ's, date of bankruptcy/insolvency/CCJ's date bankruptcy/insolvency/CCJ discharged or settled, etc.)
Have you, or any other partner or director ever had any previous insurance refused/declined, cancelled, renewal refused or had any special terms imposed? Yes No
If yes, please provide details:(e.g. reason for refusal/declinature details of any special terms imposed, etc.)
Have you been a director or officer of a company that has been declared insolvent, or had a receiver or liquidator appointed, or entered into arrangements with creditors in accordance with the Insolvency Act 1986? Yes No
If yes, please provide details:(e.g. name of director / officer, name of previous insolvent company amount(s) of insolvency, date of insolvency, amount of any outstanding debts, etc.)
Have you ever been disqualified from being a company director? Yes No
If yes, please provide details:(e.g. name of director, reason for disqualification, name of previous company, date disqualified, etc.)
Have you ever been prosecuted under any Health & Safety or Environmental Protection legislation, or been served a Prohibition or Improvement Order under Health & Safety legislation? Yes No
If yes, please provide details:(e.g. date of prosecution / prohibition order, reason for prosecution / prohibition order, details of improvement made to avoid re-occurrence, etc.)
HMRC / Inland Revenue Investigations
Has the business ever been subject to an investigation or recovery action by HM Revenue and Customs or the Inland Revenue? Yes No
If yes, please provide details:
Vehicle Ownership
Are all vehicles to be covered owned by, or hired / leased to the proposer? Yes No
If no, please provide details:
Are any of the vehicles to be insured personally owned by any directors? Yes No
If yes, please provide details:(e.g. Make/Model of Vehicle(s) and Registration Number(s) of Vehicle(s))
Dangerous Goods / Locations
Do any of the vehicles carry any dangerous goods or substances, as defined by the Carriage of Dangerous Goods regulations? Yes No
If yes, please provide details:(e.g. details of dangerous substances carried, volume or quantity of the dangerous substance carried, Registration Number(s) of vehicle(s) carrying the substances)
Will any of the vehicles visit any hazardous locations?(such as (but not limited to) power stations, dockside, nuclear installations, refineries or bulk storage or production premises in the oil, gas or chemical industries, Ministry of Defence premises, military bases, airside at any airport, rail trackside or other rail property, etc.) Yes No
If yes, please provide details:(e.g. type of hazardous location(s), Registration Number(s) of vehicle(s) visiting the locations)
Driving Licences
Do all drivers hold valid licences required by law to drive the vehicles to which they are assigned? Yes No
If no, please provide details:
Operators Licence
Do you hold an Operator's Licence? Yes No
If yes, type of Operator's Licence held:
- - - - - - - - - Please Select - - - - - - - - -
Operator - Haulage (International
Operator - Haulage (Non-International)
Operator - Restricted
PCV
Operator Licence Postcode:
Non-Motoring Convictions
Has any person who, to your knowledge will drive under this insurance, ever been convicted for any criminal offence unless spent under the rehabilitation of offenders act? Yes No
If yes, please provide details:(i.e. name of driver(s), date of conviction(s), type / details of conviction, was there a custodial sentence, amount of any fine(s) (if applicable))
Trading Experience
How many years has your business been trading?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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19
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25
26
27
28
29
30
30+
year(s)
Insurance Details
Cover required: Comprehensive Third Party Fire & Theft Third Party Only
Use required:(Please tick all those applicable) Social, Domestic & Pleasure ex. Commuting Social, Domestic & Pleasure inc. Commuting Business Use Carriage of Own Goods Haulage Self-Drive Hire Public Hire Private Hire Other (please describe below):
Do you require cover for driving outside of the UK? Yes No
If yes, please state type of territories and the frequency of work spent at the location(s):
Drivers
Please confirm the driving restriction required: Any Driver (regardless of age) Any Driver Over 21 Any Driver Over 25 Named Drivers
Drivers Claims (within last 3 years)
Have you or any other driver who will drive the vehicles had any accidents or claims in the last three years? Yes No
If yes, please provide details:
Driving Convictions (within last 5 years and/or ALL Convictions involving a ban)
Have you or any other driver who will drive the vehicles been convicted of any motor offence within the last 5 years and ALL convictions involving a ban? Yes No
If yes, please provide details:
Medical Conditions
Do you or any other driver who will drive the vehicles have any medical conditions or disabilities? Yes No
If yes, please provide details:
Drivers Under 25, Over 65, or With Less Than 2 Years Full UK Licence
Do you have any drivers aged under 25, or over 65, or with less than 2 years full UK licence? Yes No
Details of Driver
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
21 years
22 years
23 years
24 years
25 years
26 years
27 years
28 years
29 years
30 years
30+ years
Type of licence:
Full UK
Provisional UK
EU Provisional
EU Full
HGV Class 1
HGV Class 2
HGV Class 3
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
Proposer's Employee
Proposer's Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Do you have any other drivers aged under 25, or over 65, or with less than 2 years full UK licence? 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
21 years
22 years
23 years
24 years
25 years
26 years
27 years
28 years
29 years
30 years
30+ years
Type of licence:
Full UK
Provisional UK
EU Provisional
EU Full
HGV Class 1
HGV Class 2
HGV Class 3
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
Proposer's Employee
Proposer's Employer
Sister-In-Law/Brother-In-Law
Spouse
Tenant
Unrelated
Alternatively, if you wish to upload your fleet vehicle spreadsheet / schedule, or have more than 10 vehicles, press the button below to upload a spreadsheet / schedule of vehicles:
Modifications
Have any of the above vehicles been modified? Yes No
If yes, please provide details:(i.e. Registration Number(s) of modified vehicle(s) and details of modifications)
Trailers
Do you require cover for trailers? Yes No
If yes, please confirm the number of trailers owned, hired, leased or lent to you?
If yes, is trailer cover required: Only whilst attached to a vehicle Whilst attached or detached
Temporary / Casual Drivers
Are Temporary / Casual / Agency Drivers employed? Yes No
If yes, what is the maximum number of Temporary / Casual / Agency Drivers employed at any one time?
Risk Management
Are any of the following risk management features in place?(discounts may be available if you carry out any of the following)
1. All drivers are supplied with Driver Handbooks? Yes No
2. Drivers supplied with details of what to do following an accident? Yes No
3. New drivers are vetted for previous motor accidents driving convictions and have their driving licence checked? Yes No
4. Existing drivers have their driving licences checked at least annually? Yes No
5. All new drivers undergo an assessment of their driving ability? Yes No
6. Procedures are in place for driving incident reporting and investigation? Yes No
7. Procedures are in place for recording and carrying out analysis of driving incidents? Yes No
8. Driver Training - Goods Carrying Vehicles - S.A.F.E.D. Yes No
Cover Start Date or Renewal Date: (dd/mm/yyyy)
Current Annual Premium / Best Quotation (£'s): This may help us to get you a better quote
Name of Current/Previous Insurer: (e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc.)
Upload 3 Years Confirmed Claims Experience
In order for us to provide you with a quotation, please press the button below to upload your last 3 years fleet Confirmed Claims Experience (CCE) form below: