Free Insurance Quotation From Direct Electronic

If you have any problems completing the form, you may wish to consult our list of Frequently Asked Questions

Motor Vehicle Insurance Details Form

UK Only

As quotes can only be accurate at the time of issue please tell us the renewal date of your existing policy. Your application will be acknowledged and the quotation sent ahead of your renewal date.

Renewal Date of Existing Insurance:
or
Immediate Cover Required: Yes No

In addition to our quotation, do you wish to have a quotation from any particular insurer such as Commercial Union, General President, Guardian, Lloyds or Norwich Union? If so, please specify:

Proposer Details

     e-mail address: 
         First name: 
          Last name:  Title:
            Address: 
                     
      

          Post Code: 
  Home Phone Number: 
  Work Phone Number: 
         Fax Number: 
        
      Date of Birth:  
     Marital Status: Single Married 

   Usual Occupation:    
  
    Type of Licence: Full Provisional   Other: 
           Held for:  years

Vehicle Details

 
   Car Manufacturer:   
              Model:   
        Engine Size:  litres
  Registration Date: 


   Value of Vehicle: 
    Number of Doors: 
    Number of Seats: 

              Alarm: Yes   
                     No
        Immobiliser: Yes   
                     No
            Tracker: Yes   
                     No



    Left Hand Drive: Yes         
                     No                                         
           Modified: Yes         
                     No                                        
   Kit Construction: Yes        
                     No          




    Vehicle kept on: Road
                     Garage
                     Private Ground

    Parked Postcode: 
   Owner of Vehicle: 
  Keeper of Vehicle:

Cover Details

     Cover Required: Comprehensive  
                     Third Party Fire and Theft 
                     Third Party Only    
                      Other (Please Specify) 

       Class of Use: Private and Pleasure   Other:       
 Used for Commuting: Yes No
            Drivers: Proposer only
                     Proposer and Spouse    
                     Proposer and 
                     Any

                    (Note: it is usually cheaper to retrict the drivers rather than to have "any")

Present and Previous Insurance Details (leave blank if not applicable)

 
    Present Insurer: 
         Years Held: 

   Previous Insurer: 
       Date Expired: 
         Years Held: 


No Claims Bonus entitlement:    Protected: Yes No
    No of cars in household: 
                
             Annual Mileage:

Accident or Loss

 
               Claim Pending: Yes      No

if yes, please specify what sort, and the incident date:     
 Personal Injury  
Fault
Date: 

Was No Claims Bonus reduced?: Yes      No

Conviction 

Conviction Pending: Yes      No
      Swansea Code: 
              (eg SP30 = Exceeding 30 MPH)
   Alcohol Measure: 

              Fine: ú
      Disqualified: Yes      No
         How Long?:  months
    Penalty Points:
If you have any problems completing the form, you may wish to consult our list of Frequently Asked Qustions

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