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

Car Insurance

Contact Details

Complete your details in the form below and press submit. We will provide a response within one working day. Please fill in all * marked fields these are required to correctly process your quote. Failure to include accurate information could cause loss of a claim.

We need some information about you, please make sure you fill this section in carefully.

Title: *

First Name: *

Middle Name:

Surname: *

Sex: *

Marital Status: *

Licence Type: *

Years Held: *

Contact Number: *

Additional Number:

Fax Number:

Email Address: *

Street Address: *

City:

County:

Postcode: *

Birth Date: *

Occupation: *

Sector: *

Claim Questions

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?

Do you have any claims history?

Have any physical infirmity, disability, heart complaint, etc?

If you answered yes to any of the above, please supply details: *

Additional Drivers?

* If you have answered yes to additional drivers being on the policy, please make sure to fill in the next section in full. Failure to provide accurate details could lead to loss of the claim.

Details of additional drivers:

TITLE

FIRST

SURNAME

DATE OF BIRTH

OCCUPATION

DATE TEST PASSED

Motor Details:

Make: *
Model(GL, Xantia,275, etc): *
Model Type(TR, Ghia, L etc):

Engine size/cc:

Fuel type:

Registration No:

Year of Manufacture:

Standard or modified

Security

Value:

 £

Parking: *

Quotations Required(Check as appropriate)

Comprehensive:

Third Party, Fire & Theft:

Third Party only:

Business Use:

Breakdown Cover:

Any Driver over 17:

Any Driver over 25:

No. of years No Claims Discount: *

Do you wish to protect your No Claims Discount?

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 accurate and factual?

YES NO



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