SPECIAL TYPE VEHICLE INSURANCE QUOTATION
PROPOSER
Name
T/as
Trade
Sole Trader
Partnership
Limited
Trading Since
Terrirtory
UK Only
UK & ROI
ROI Only
LOCATION
Address
Postcode :
CONTACT DETAILS
Tel
Fax
Mob
Email
Web
VEHICLE DETAILS
(01)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(02)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(03)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(04)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(05)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(06)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(07)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(08)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(09)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(10)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(11)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(12)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(13)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(14)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
(15)
Reg/Serial
Type
Make/Model
Year
Value
Alarm
Modified
Seats
Cover
Working Risk
Select?
TP ONLY
TPFT
COMP
Select?
No. I have PL
Yes. Add PL
If you have more than 15 vehicles then submit your own schedule to quotations@wallace-group.co.uk
DRIVERS
PROPOSER (Main Driver)
Name (Proposer)
Date of Birth
Licence
Licence Type?
Commercial Standard
Commercial C
Commercial C1
Provisional
Full Private
European
International
Other (Give Details)
Years Held
Clean Licence:
Confirm drivers all have a clean Licences?
If Not Ticked complete below
That all drivers are aged 25 or over?
If Not Ticked complete below
YOUNG DRIVER DETAILS (Aged 25 or under)
Sec A
Name
Relationship To Proposer
DOB
1
Relationship?
Spouse/Partner
Sister
Brother
Relative
Employee
Work Collegue
2
Relationship?
Spouse/Partner
Sister
Brother
Relative
Employee
Work Collegue
3
Relationship?
Spouse/Partner
Sister
Brother
Relative
Employee
Work Collegue
4
Relationship?
Spouse/Partner
Sister
Brother
Relative
Employee
Work Collegue
5
Relationship?
Spouse/Partner
Sister
Brother
Relative
Employee
Work Collegue
Continued...
Sec B
Licence Type
Yrs Held
Clean Licence
1
(
Licence Type?
Provisional
Full
European
International
Commercial Standard
Commercial C
Commercial C1
Other (Give Details)
)
2
(
Licence Type?
Provisional
Full
European
International
Commercial Standard
Commercial C
Commercial C1
Other (Give Details)
)
3
(
Licence Type?
Provisional
Full
European
International
Commercial Standard
Commercial C
Commercial C1
Other (Give Details)
)
4
(
Licence Type?
Provisional
Full
European
International
Commercial Standard
Commercial C
Commercial C1
Other (Give Details)
)
5
(
Licence Type?
Provisional
Full
European
International
Commercial Standard
Commercial C
Commercial C1
Other (Give Details)
)
DRIVER LICENCE PENALTIES/POINTS ETC
CURRENT INSURANCE
Required Date
Current Insurer
Policy Number
Premium
Current Broker
CLAIMS RECORD
Tick if any claim in last 5 years
Give claim details, types, dates :
A Confirmed Claims experience will be required from your previous insurers. This can be obtained from your current Broker. Email to: quotations@wallace-group.co.uk
OTHER INFORMATION
Telephone 02870325999 for assistance