MotorInsurance
Tel: 01992 707313
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
Type of Business you are Employed in
Male/Female Male Female
Date Of Birth: (Day Month Year)
Date of Passing Driving Test
Is your driving licence UK or EU UK EU
Number of years resident in UK
Medical Conditions (If none, state None)
Where Did You See Us Advertised
Existing Customer (Any Product) YES NO 
Vehicle Details:  
Make & Exact Model (e.g. LX, GTi )
Number of Seats
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
If Under 8,000, please state 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
Type of Business Employed in
Male/Female Male Female
Date Of Birth: (Day Month Year)
Date of Passing Driving Test
Is your driving licence UK or EU UK EU
Number of years resident in UK
Medical Conditions (If none, state None)
   
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
Type of Business Employed in
Male/Female Male Female
Date Of Birth: (Day Month Year)
Date of Passing Driving Test
Is your driving licence UK or EU UK EU
Number of years resident in UK
Medical Conditions (If none, state None)
   
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.