| Title |
|
| First Name |
|
| Surname |
|
| Date of Birth |
|
| Day-Time Contact Number |
(Format: 0## ### ####) |
| E-mail |
|
| Gender |
|
| Which of the following
best describes your current insurance history? |
|
| Has your insurance cover
ever been cancelled for a poor claims experience, or have you ever been advised
to seek alternative insurance? |
|
| With regards to you as
the Regular Driver. How many vehicle thefts, hijackings or accident claims /
incidents have you had in the last 3 years? |
|
| As, as the Regular
Driver, which description best fits you? |
|
| The vehicle or vehicles
you wish to insure, is it a small car with a large sporty engine? (i.e. Golf
GTi, Toyota RSI, Opel GSi, Mini Cooper S, Renault Clio Sport, Peugeot 206 GTi
or similar) |
|
| Colour of Vehicle? |
|
| Vehicle use |
|
| Vehicle mileage per
annum? |
|
| |
|
|
|