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Van Insurance Quotation
To help us provide you with out best possible quotation, please complete as much of the following quotation form as you can.
More information about this quotation
Policy Holder Details
Email Address (
Required
)
Trading Name (If Applicable)
Title:
Mr
Mrs
Miss
Ms
Dr
Forename: (
Required
)
Surname: (
Required
)
Address: (
Required
)
PostCode: (
Required
)
Home Phone number:
Work Phone Number: (
Required
)
Fax Number:
Occupation:
Vehicle Details
Vehicle Registration Number
Vehicle Manufacturer:
eg. Volkswagen
VehicleModel:
eg. Transporter
Engine Size
eg. 2448cc or 2.5
Vehicle Type
Van
Pickup
Lorry
Truck
Gross Vehicle Weight / Carrying Capacity
eg. 1500kg
Year Of Registration:
Reg Letter:
Q Plated
No
Yes
Date Of Registration
Date Purchased
Vehicle Value
Purchase Price
Fuel Type:
Petrol
Diesel
Transmission Type:
Manual
Automatic
Colour Of Vehicle
Paint Finish
Non Metalic
Metalic
Pearl
Number Of Doors
Left Hand Drive:
No
Yes
Alarm Fitted:
No
Yes
(If yes - Make & Model)
Imobiliser Fitted:
No
Yes
(If yes - Make & Model)
Tracker Fitted:
No
Yes
Vehicle Modifications:
Body kits, etc
Vehicle Kept:
Drive
On Road
In Garage
Private Property
Locked Compound
Vehicle Owner
Please Select
Proposer
Company
Vehicle Keeper
Please Select
Proposer
Company
Parked Postcode
Annual Personal Mileage
Annual Business Mileage
Total Mileage
Current Odometer Reading
Odometer Reading Date
Insurance Cover Details
Quotation Required
Comprehensive
Third Party Fire and Theft
Third Party Only
Comprehensive & Third Party Fire and Theft
Drivers:
Proposer Only
Proposer and Spouse
Proposer and One Named Driver/option>
Any Driver
Any Driver Over 21
Any Driver Over 25
Vehicle Useage
eg. Carrage of own goods, haulage etc.
Excess Required
eg £250
Number of Years No Claims
Is protected bonus required
No
Yes
Previous Insurance Company
Insurance Expiry Date
Proposer Type
Individual
Company
Driver 1 Details
Title:
Mr
Mrs
Miss
Ms
Dr
Forename:
Surname:
Date Of Birth
Marital Status:
Single
Married
Common Law
Driving Licence Type:
Full (UK)
Provisional
Years Licence Held For :
Resident In UK Since
This Driver Is
Main User
Regular Driver
Casual Driver
Medical Conditions
Driving Qualifications
Ever Been Refused Insurance
Yes
No
Ever Had Terms Imposed
Yes
No
Home Owner:
No
Yes
(If yes how long
Years)
Occupation
Employment Status
Employed
Self Employed
Accidents / Claims Or Any Losses In The Last 5 Years
Fault / Non Fault
Motor Convictions In Last 5 Tears
Ever Had Suspensions
Yes
No
Any Criminal Convictions
Yes
No
WestPennine Insurance Services Group is the trading name of WestPennine Insurance Consultants Limited. Registered Office 84 Church Street, Littleborough. OL15 8AU. Registered in England number 939318
Telephone 01706 378990 Fax 01706 371417
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