R T Waters Ltd



141605-487045Motor Quotation Form:020000Motor Quotation Form:-144145-13970000POLICYHOLDER DETAILS:Title: First Name: Surname: Address: Post Code: Home Telephone Number: Mobile Telephone Number: Email Address: Are you a home owner:Yes: ?No: ?Owner & registered keeper of the vehicle: If Other Please State Owner: VEHICLE DETAILS:Make: Model: Engine Size (cc): Registration Number: Standard Audi/Satnav:Yes: ? No: ?Body Type: Fuel Type: Transmission: Number of Doors: Number of Seats: Value:? Purchase Date: Registration Date: Security Fitted to Vehicle: Is Your Vehicle Fitted with a Tracking Device: Yes: ?No: ?Steering Orientation: Vehicle Imported: Vehicle Modified: If yes please give details below: Postcode where vehicle kept overnight: Location Vehicle Kept Overnight: What do you use the vehicle for: Annual Mileage: If Business Use Selected please indicate approx. number of business miles from within the figure given: COVER AND USE:Cover Required: Date Policy Due: Years No Claims Bonus: Do you wish to protect your No Claims Bonus: Yes: ? No: ?Renewal Quotation:Current Insurer: Current Renewal Premium: Current Excess: Preferred Excess? Best Alternative Quotation:Alternative Insurer: Alternative Premium: Alternative Excess: DRIVER DETAILSDriver 1:Driver 2:Driver 3:Driver 4:Title: First Name: Surname: Date of Birth: Relation to Proposer: Marital Status: Occupation/Job Title: Employers Business: Employment Status: Secondary Occupation:Occupation/Job Title: Employers Business: Employment Status: Type of Driving Licence Held: If International please state country of issue: If International please state country of issue: If International please state country of issue: If International please state country of issue: Date Test Passed: Years Resident in the UK: Years Months Years Months Years Months Years MonthsFrequency of Use:(Only 1 Driver can be Main User) Number of Cars In Household: Access to other vehicles:Owned: As A Named Driver: Owned: As A Named Driver: Owned: As A Named Driver: Owned: As A Named Driver: Accidents/Claims in the last 5 year on any vehicle irrespective of blame:Yes: ?No: ? Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?(Please provide full details on next page)Motoring Convictions in last 5 years:Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?(Please provide full details on next page)General:Refused, Cancelled or Voided Policies:Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Previous Criminal Convictions:Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Previous Terms Imposed:Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?County Court Judgements, Bankruptcy or Individual voluntary arrangements:Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?ACCIDENTS/CLAIMS: Please show below any accidents thefts or losses (irrespective of blame and whether a claim resulted) which you or any other person who will drive have incurred in the last 5 years: Driver Number:Accident Type:Fault or Non-Fault:Description of Incident:Date:Amount Paid by Insurer Damage: ? Injury Cost: ? Damage: ? Injury Cost: ? Damage: ? Injury Cost: ? Damage: ? Injury Cost: ? MOTORING CONVICTIONS: Please show below any Unspent Convictions, Driving Licence Endorsements, Fixed Penalty Offences or Pending Prosecutions which you or any other person who will drive have incurred in the last 5 years: Driver Number:Conviction Code:No. of Points:Fine:Date of Offence:Date of Conviction:Disqualified from Driving:(if Yes please state length of ban) ? *Yes: ? No: ? Years Months ? *Yes: ? No: ? Years Months ? *Yes: ? No: ? Years Months ? *Yes: ? No: ? Years MonthsMEDICAL CONDITIONS: Does Any Driver suffer from any disabilities or infirmities that may affect their driving?Driver Number:Condition:Date Sustained:Driver on Medication:DVLA Notified:Registered Disabled:Blue Badge Holder: Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ? Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ? Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ? Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Yes: ?No: ?Please confirm that the answers you have given are complete and accurate to the best of your knowledge and that you understand that any inaccuracies or non-disclosures may invalidate your cover. For example, claims, convictions & modifications to your vehicle. Yes ? No ?Some insurers perform external data searches prior to calculating a premium. These will include information obtained from the DVLA and a credit check which will appear on your credit history whether you proceed or not. Is this OK? Yes ? No ? ................
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