Car Insurance Quote Form - primeinsuranceltd.co.uk

How did you hear about us?

Recommended by: Please enter their name & number below

Title:*

First Name*

Surname*

Date of Birth*

House Number/Name*

Postcode*

First Line of Address*

Marital Status*

Any Children Under 16?*

Employment Status*

If Employed/Self Employed, what is your occupation:

If Employed/Self Employed, what type of business:

Your Email*:

Your Mobile*:

Your Phone:

Please contact me via
PhoneTextemail

Driving History

Type of License*

Period Licence held for*

If held for 4 years or less, what date was licence obtained

Would you like to enter your driving licence number? (optional)
Please enter your 16-character GB driving licence number. This may reduce your price.

DVLA medical conditions or disabilities*

Any additional driving qualifications*

If one is selected, what date was qualification obtained

Were you born in the UK*

If No, when did you last become a UK resident

Use of any other vehicles*

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years:
YesNo

Motor Accidents or Claim Details

1st Accident Details

Type:

Date:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:
YesNo

2nd Accident Details

Type:

Date:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:
YesNo

3rd Accident Details

Type:

Date:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:
YesNo

4th Accident Details

Type:

Date:

Damage:

Cost(£) - if known:

Fault:

Any Injuries:
YesNo

Any motor convictions, fixed penalties or disqualifications in the last 5 years:
YesNo

Motor Conviction, Fixed Penalty or Disqualification Details

1st Details

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

2nd Details

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

3rd Details

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

4th Details

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

Vehicle Details

Vehicle Registration* (Enter if you know)

Approximate value of the car right now?

Does the vehicle have any modifications?*

Have you purchased the vehicle?:*

Enter date of purchase:

Registered Keeper:*

Legal Owner:*

Is the car impounded with the police?

Vehicle Usage

Where is the vehicle kept during the day:*

Where is the vehicle kept overnight:*

Use of vehicle:*

Is the vehicle kept at the same address:*

If No, what is the full address of where the vehicle is kept (optional):

Have you or any of the drivers ever had insurance declined, cancelled or special terms imposed?*

Estimated Annual Mileage:*

Type of Cover:*

Any no claims discount:*

How did you earn your no claims discount:

Was this NCD earned in the UK:

Would you like to protect your NCD:

What voluntary excess would you like: (Enter amount or 0 for NONE)*

How do you normally pay for insurance:*

Please provide your Current/Previous Insurer’s name, this may reduce your price:
Insurer Name

When would you like the policy to start:*

Additional Driver (If any)

Would you like to add an additional driver
YesNo

Title*

First Name*

Surname*

Date of Birth*

Marital Status*

Relationship to Proposer/Policy Holder*

Employment Status*

If Employed/Self Employed, what is your occupation:

If Employed/Self Employed, what type of business:

Type of License *

Period Licence held for*

If held for 4 years or less, what date was licence obtained

Enter your driving licence number? (optional)

Would you like to enter your driving licence number? (optional)

DVLA medical conditions or disabilities*

Were you born in the UK*
If No, when did you last become a UK resident

Use of any other vehicles*

Non motoring criminal convictions
Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years *
(Only enter if you have made any claims otherwise leave blank)

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions?*
(Only enter if you have any details or leave blank if you have no motoring offence)

Would you like to add an additional driver
NoYes

Title:*

First Name:*

Surname:*

Date of Birth*

Marital Status:*

Relationship to Proposer/Policy Holder*

Employment Status: *

If Employed/Self Employed, what is your occupation:

If Employed/Self Employed, what type of business:

Type of License: *

Period Licence held for*

If held for 4 years or less, what date was licence obtained

Enter your driving licence number? (optional)

Would you like to enter your driving licence number? (optional)

DVLA medical conditions or disabilities:*

Were you born in the UK:*
If No, when did you last become a UK resident

Use of any other vehicles*

Non motoring criminal convictions
Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years: *
(Only enter if you have made any claims otherwise leave blank)

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions?*
(Only enter if you have any details or leave blank if you have no motoring offence)

Any additional comments

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CAR INSURANCE QUOTATION FORM

Personal Info

Contact Details

Driving History

Motor Accidents or Claim Details

Motor Conviction, Fixed Penalty or Disqualification Details

Vehicle Details

Vehicle Usage

Additional Driver (If any)

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