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Contact Name:
Sex:
M F
Phone Number:
Mobile Number:
Fax Number:
Email Address:
Address:
Postcode:
Birth Date:
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Occupation:
Make:
Model(GL, Xantia,275, etc):
Model Type(TR, Ghia, L etc):
Engine size/cc:
Fuel type:
Petrol Diesel LPG Multi-fuel
Registration No:
Year of Manufacture:
Standard or modified
Standard Modified, add details
Security
Standard security Extra security
Value:
£
Parking:
Off Road (Driveway) Off Road (Garage) On Road
Insured Only
Insured and spouse
Insured and named drivers
Any driver over 25
Any driver over 30
NAMES
DATE OF BIRTH
OCCUPATION
DATE TEST PASSED
Have you or any person who may drive:
YES
NO
In the last 5 years had any motoring convictions or have any pending, or even been suspended from driving?
In the last 5 years had any accidents of losses, - Fire/Theft, etc?
Have any physical infirmity, disability, heart complaint, etc?
If yes, please supply details:
Quotations Required(Check as appropriate)
Comprehensive:
Third Party, Fire & Theft:
Third Party only:
This vehicle is used for:
Travel to work:
Social, domestic and pleasure only:
Business (by self only):
Business(by others):
No. of years No Claims Discount:
Do you wish to protect your No Claims Discount?
Yes No Possibly
Who is your current Insurer?
When is your motor insurance renewal date?
Are there any other material facts which may affect this quotation? If yes, please supply details:
Additional Comments:
Do you agree that the infomation you have entered is factual?
STUART & CO, STUART HOUSE, 15 RAMSAY COURT,HINCHINGBROOKE BUSINESS PARK, HUNTINGDON, CAMBS, PE29 6FY
TEL +44 01480 433443 FAX +44 01480 431060 Email : sales@stuartandco.co.uk