Motor Insurance Quote Request
To obtain a quote, please complete the following, and press the "Submit Request" button at the bottom of the form. We will contact you by telephone or email with a quote.
E-Mail Address
Confirm email Address  
Title
First Name
Second Name
Surname
Married or Single Married Single
House No./Name
Company Name/Trading Name
Street
Town
County
Post Code
Country
Tel. Number - Day.
Mobile Number (if different from above)
Tel Number - Evening
Occupation
Part Time Occupation
Date Of Birth: (Day Month Year)
Date of Passing Driving Test
Medical Conditions
Where Did You See Us Advertised
Existing Customer (Any Product) YES NO 
Vehicle Details:  
Make & Exact Model (e.g. LX, GTi )
Petrol, Diesel or other (If other state type)
Engine Capacity
Year of Make
Registration Number
Date vehicle purchased (Day/Month/Year)
Value
What is the Vehicle Used For
Type of Cover
Alarm/Immobiliser
Thatcham Approved
   
No Claims Bonus
Protected Bonus
Voluntary Excess £
Vehicle Kept Overnight
Annual Mileage
Present Insurers
Renewal Premium
Renewal Date
Accidents/Claims in the last 3 years:  
Date
Type
Amount Claimed
Whose Fault
Was Claims Discount Lost YES NO 
Convictions:  
Date
Offence Code
Fine £
Points
Months Banned
Additional Drivers:
   
First Additional Driver Details:
Title
First Name
Surname
Occupation
Date Of Birth: (Day Month Year)
Date of Passing Driving Test
Medical Conditions
   
Accidents/Claims in the last 3 years:  
Date
Type
Amount Claimed
Whose Fault
Was Claims Discount Lost YES NO 
Convictions:  
Date
Offence Code
Fine £
Points
Months Banned
   
Second Additional Driver Details:
Title
First Name
Surname
Occupation
Date Of Birth: (Day Month Year)
Date of Passing Driving Test
Medical Conditions
   
Accidents/Claims in the last 3 years:  
Date
Type
Amount Claimed
Whose Fault
Was Claims Discount Lost YES NO 
Convictions:  
Date
Offence Code
Fine £
Points
Months Banned
 

Additional Information/Comments

(pressing 'enter' at the end of each line)
   
Declaration: I declare that the information I have given above is true and complete. I have not withheld any material facts (see IMPORTANT NOTES.) I agree that this proposal shall form the basis of the Contract between me and Shearwater Insurance.
Shearwater Insurance Services Ltd
Registered Office: 2 Bath Place, London, EC2A 3JJ. Registered in the UK Company No: 02701633