N.R. Daws Insurance Consultants Ltd.

Types of cover available:

Comprehensive	-	This offers the widest cover, including repairs to your own vehicle, windscreen cover, personal effects, recovery of your vehicle after an accident, personal accident cover. Vehicle breakdown cover is also available with some policies.
Third Party, Fire & Theft	-	This covers your liability to third parties and offers cover if your vehicle is stolen or catches fire. There is no cover to your vehicle if it is involved in an accident.
Third party only	-	This covers your liability to third parties only. There is no cover for your vehicle.

To request a motor insurance quotation, please complete the form below and we will e-mail you a quote.

Please complete the form below as fully and accurately as possible to assist us in providing your quotation. If you have any queries please e-mail us.

Proposer Details

Title:

Mrs Miss Ms Mr Dr

First name:

Surname:

Number and Street

Town/City

County

Postcode

Telephone Number:

E-mail Address

Postcode, where vehicle is normally kept, if different

Date of Birth: (dd/mm/yy)

Gender:

Male Female

Marital Status:

Married Single Common Law Married

Occupation(s)
If more than one, state all

Employers Business:

Type of UK Licence held:

Full Provisional International

Date UK Driving Test passed (dd/mm/yy)

Resident in UK for past 3 years

Yes No

Additional Driver(s)

Date of Birth: (dd/mm/yy)

Gender:

Male Female

Marital Status:

Married Single Common Law Married

Occupation(s)
If more than one, state all

Employers Business:

Type of UK Licence held:

Full Provisional

Date UK Driving Test passed (dd/mm/yy)

Resident in UK for past 3 years

Yes No

Date of Birth: (dd/mm/yy)

Gender:

Male Female

Marital Status:

Married Single

Occupation(s)
If more than one, state all

Employers Business:

Type of UK Licence held:

Full Provisional

Date UK Driving Test passed: (dd/mm/yy)

Resident in UK for past 2 years

Yes No

Vehicle Details

Where additional details are required, please enter them in the additional details section at the end of this form.

Manufacturer:

Model (include GL/GT etc):

Type of Body and Number of Seats:

Cubic Capacity:

Year of Make:

Registration Letters & Numbers:

Purchase Date (mm/yy):

Purchase Price:

Present Value:

Is a security device fitted?

Yes No

Has the vehicle been modified or altered from maker's specification, whether by you or anyone else, (including body kits, alloy wheels, spoilers, engine, suspension, etc.) or do you intend to alter it? Yes

Do you own the vehicle?

Yes No

Is the vehicle registered in your name?

Yes No

Do you hold or have held a previous motor insurance policy?

Yes No.

If Yes, please state name of recent insurer, policy number and date of expiry.

Years entitlement to No Claim Discount:

Have you or any other person who may drive, in the last five years, been declined or refused insurance or offered cover requiring either endorsement of special terms on the policy or an increased premium. Yes No

Have you or any other person who may drive suffered from any physical or mental disability, infirmity or disease or illness (including any condition which is required to be reported to the DVLA in relation to holding a driving licence)?
Yes No

Is the car kept in a locked garage at night?

Yes No

Have you or any other person who may drive had any accident or loss (by fire, theft or any other cause whatsoever) in the last THREE years involving any motor vehicle (of any kind) whether owned, driven or in custody? This includes any accident or loss not covered or claimed under an insurance policy, and whether at fault or not. Yes No

Have you or any other person who may drive been convicted of any offence (including speeding or fixed penalty offence) or disqualified from driving in the last FIVE years?

Yes No.
If Yes please give details.

Have you or any other person who may drive been given notice of prosecution or warned that a prosecution is under consideration for any offence, but which has not yet been tried?

Yes No.
If Yes please give details.

Insurance Cover and Use

Comprehensive
Please tick voluntary excess required:

£100

£150

£200

£250

Third Party, Fire and Theft

Third Party only

Driving restriction required:

Yourself only	Yourself and spouse
Yourself, and one named driver	Yourself, and two named drivers
Any driver over 30 years of age	Any driver over 25 years of age

Protected NCD option
(only allowed with full NCD and subject to an additional £50 excess)

Yes No

Use required:

Social, Domestic & Pleasure Class 1
Class2 Class 3

Additional Details:

NR Daws Insurance Consultants Ltd.
6a Shortmead Street, Biggleswade, Bedfordshire SG18 0AP
Tel: 01767 314798	Fax: 01767 312200	E-mail: info@nrdaws.co.uk
Authorised and regulated by the Financial Services Authority. Registration No 308647 Registered in England Registration No 5077090 Incorporating D. M. Insurance Services & Stotfold Insurance Services