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Individual Bonus Rated Policies Quotation
These policies can be single or multi-vehicle policies were the individual vehicle(s) are rated on a 'no-claim bonus', just like a private car policy. The advantage of this type of policy is that a claim against one vehicle will not affect the a 'no-claim bonus' on any other vehicle(s)
To help us provide you with out best possible quotation, please complete as much of the following quotation form as you can.
Title
Mr
Mrs
Miss
Ms
Dr
Name
Trading Name
Address
Address 2
Address 3
Address 4
Postcode
Telephone
Email
About your vehicle
Vehicle Manufacturer
Vehicle Model
Engine size
Year of manufacture
Reg letter
Fuel Type
Petrol
Diesel
LPG
Transmission
Manual
Automatic
Number of seats
Vehicle value
Left hand drive
No
Yes
Please advise vehicle security as follows
Is the vehicle alarmed
No
Yes
If alarmed:
Make & Model
Imobiliser fitted
No
Yes
If imobiliser fitted:
Make & Model
Tracker fitted
No
Yes
Driver details
Cover required
Comprehensive
Third Party Fire & Theft
Third Party Only
Drivers
Proposer Only
Proposer and Spouse
Proposer and One Named Driver
Any Driver
Any Driver Over 21
Any Driver Over 25
Class of use
Carriage of own goods
Carriage of goods for hire or reward
Number of years no claims bonus
Protected bonus
No
Yes
Vehicle kept
In Garage
On Own Ground
On Road
Parked postcode
Are you the owner of the vehicle
No
Yes
Are you the keeper of the vehicle
No
Yes
Your date of birth
Marital status
Single
Married
Licence Type
Full (UK)
HGV
Provisional
Date passed (UK) driving test
Do you have access to other cars in the family
No
Yes
Resident in the UK since
Details any disabilities
Occupation
Type of business
Proposer Claims in the last 5 Years
eg. Date, value, who's fault, pending(y/n) bonus reduced(y/n)
Proposer conviction 1 in the last 5 Years (11 yrs for DR10)
Conviction Pending:
No
Yes
Conviction Code:
e.g. SP30 Conviction
Date:
e.g. 12/04/03
Alcohol Measure:
Units
Disqualified:
No
Yes
(If yes How Long for)
Months
Fine:
Penalty Points:
Proposer conviction 2 in the last 5 Years (11 yrs for DR10)
Conviction Pending:
No
Yes
Conviction Code:
e.g. SP30 Conviction
Date:
e.g. 12/04/94
Alcohol Measure:
Units
Disqualified:
No
Yes
(If yes How Long for)
Months
Fine:
Penalty Points:
Additional Drivers Details (if required)
Name
Date of birth
Marital status
Single
Married
Occupation
Type of business
Licence Type
Full (UK)
HGV
Provisional
Date passed (UK) driving test
Resident in the UK since
Details any disabilities
Relatonship to proposer
Additional Driver Claims in the last 5 Years
eg. Date, value, who's fault, pending(y/n) bonus reduced(y/n)
Additional Driver 2 conviction 1 in the last 5 Years (11 yrs for DR10)
Conviction Pending:
No
Yes
Conviction Code:
e.g. SP30 Conviction
Date:
e.g. 12/04/94
Alcohol Measure:
Units
Disqualified:
No
Yes
(If yes How Long for)
Months
Fine:
Penalty Points:
Additional Driver conviction 2 in the last 5 Years (11 yrs for DR10)
Conviction Pending:
No
Yes
Conviction Code:
e.g. SP30 Conviction
Date:
e.g. 12/04/94
Alcohol Measure:
Units
Disqualified:
No
Yes
(If yes How Long for)
Months
Fine:
Penalty Points:
Ever been declared bankrupt or insolvent?
Please Select
Yes
No
Been convicted of any criminal offence, which is not 'Spent'?
Please Select
Yes
No
Had any County Court Judgements entered in the last six years?
Please Select
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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