Car Insurance Quote

Please take care to answer all the questions honestly and to the best of your knowledge. Failure to do so could effect your level of cover, amount payable, your policy cancelled or any claims that you make rejected.

Your Personal Details

Title*

First Name(s)*

Surname*

Gender*

Male
Female

Date of Birth*

Please enter the date in the format DD/MM/YYYY, e.g. 21/01/1975.

Have you been a permanent resident of the UK since birth?*

Yes
No

When did you become a UK resident?*

Marital Status*

Are you a homeowner?*

Yes
No

Contact Information

House name or number*

Street*

Town*

Postcode*

What type of property is this?*

Daytime telephone number*

Please remember to include your STD area dialling code, e.g. 0207

Evening or mobile phone number*

For landlines, please remember to include your STD area dialling code, e.g. 0207

Email address*

This email address may be used to contact you about this quote.

Employment Information

What is your employment status?*

What is your occupation?*

Please enter your job description. This will generate a list from which you can select the most appropriate description. For example: If you work in a call centre, you should enter Telesales Person or Customer Advisor. NB: If you have entered only part of your job description and you are unable to find your job in the list, please enter more characters to refine the list.

What is your employer's business? e.g. Retailing*

Please enter a description of your employer's general area of business. This will generate a list from which you can select the most appropriate description. For example: If you work in a high street shop, you should enter Retailing. NB: If you have entered only part of your employer's business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Your business type*

Please enter a description of your general area of business. This will generate a list from which you can select the most appropriate description. For example: If you work in a high street shop, you should enter Retailing. NB: If you have entered only part of your business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Line of Business*

Please enter a description of your general area of business. This will generate a list from which you can select the most appropriate description. For example: If you work in a high street shop, you should enter Retailing. NB: If you have entered only part of your business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Do you have a Part-Time or an Additional Job?*

Yes
No

Part-time Employment Information

What is your part-time employment status?*

What is your part-time occupation?*

Please enter your part-time job description. This will generate a list from which you can select the most appropriate description. For example: If you work in a call centre, you should enter Telesales Person or Customer Advisor. NB: If you have entered only part of your job description and you are unable to find your job in the list, please enter more characters to refine the list.

What is your part-time employer's business? e.g. Retailing, Insurance or Building Trade*

Please enter a description of your part-time employer's general area of business. This will generate a list from which you can select the most appropriate description. For example: If you work in a high street shop, you should enter Retailing. NB: If you have entered only part of your employer's business and you are unable to find the correct business in the list, please enter more characters to refine the list.

What is your part-time business type? e.g. Retailing, Insurance or Building Trade*

Please enter a description of your part-time general area of business. This will generate a list from which you can select the most appropriate description. For example: If you work in a high street shop, you should enter Retailing. NB: If you have entered only part of your business and you are unable to find the correct business in the list, please enter more characters to refine the list.

What is your part-time line of business? e.g. Retailing, Insurance or Building Trade*

Please enter a description of your part-time general area of business. This will generate a list from which you can select the most appropriate description. For example: If you work in a high street shop, you should enter Retailing. NB: If you have entered only part of your business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Your Driving

What type of driving licence do you hold?*

When did you obtain your licence?*

Do you have any medical conditions that affect your driving?*

Yes
No

Have you notified the DVLA of your medical condition?*

Yes
No

Telling DVLA about a medical condition or disability

You must tell DVLA if you have a driving licence and:

you develop a ‘notifiable’ medical condition or disability
a condition or disability has got worse since you got your licence

Notifiable conditions are anything that could affect your ability to drive safely. They can include:

epilepsy
strokes
other neurological and mental health conditions
physical disabilities
visual impairments

You could be fined up to £1,000 if you don’t tell DVLA about a condition that might affect your ability to drive safely. You could also be prosecuted if you have an accident.

By phone

DVLA drivers’ medical enquiries
Telephone: 0300 790 6806
Monday to Friday, 8am to 5:30pm
Saturday, 8am to 1pm

Have you ever been refused car insurance, or ever had an insurance policy voided or cancelled?*

Yes
No

Claims and Convictions

Have you made any Claims in the past 5 years?*

Yes
No

Add a Claim for Driver

When was the claim made?	Claim description	Was the No Claims Discount affected?	Costs of repairs to the insured vehicle	Cost of third party repairs	Was there any personal injury?
When was the claim made?	Claim description	Was the No Claims Discount affected?	Costs of repairs to the insured vehicle Please enter a value greater than or equal to 0.	Cost of third party repairs Please enter a value greater than or equal to 0.	Was there any personal injury?	Add another Add a Claim for Driver Remove this Add a Claim for Driver

Was the No Claims Discount affected? If you are held liable for a claim, your No Claims Discount could be affected. Examples include: • You are held responsible for an accident • Your car is stolen • Your car is hit by an uninsured or hit-and-run driver Cost of repairs to the insured vehicle: Please enter the cost of the repairs to your car. If you are unsure of this, please provide an estimate. If there were none, please enter 0. Cost of third party repairs: Please enter any third party costs. If you are unsure of this, please provide an estimate. If there were none, please enter 0.

Do you have any Convictions in the past 5 years?*

Yes
No

Conviction

Date of conviction	Conviction type / code	How many points received? (enter 0 if none)	How much was the fine? (if applicable) (enter 0 if none)	Was the driver banned? (if applicable)	How many months was this for? (if applicable)	Type of alcohol reading taken	Level of reading taken
Date of conviction	Conviction type / code	How many points received? (enter 0 if none)	How much was the fine? (if applicable) (enter 0 if none) Please enter a value greater than or equal to 0.	Was the driver banned? (if applicable)	How many months was this for? (if applicable)	Type of alcohol reading taken	Level of reading taken	Add another Conviction Remove this Conviction

Conviction Type / Code: This is the conviction code as it appears on the driver's driving licence, e.g. SP30 Level of reading taken: If the alcohol reading was taken from: Breath: Please enter the micrograms of alcohol per 100 millilitres of breath. The legal limit is 35Âµg Blood: Please enter the milligrams of alcohol per 100 millilitres of blood. The legal limit is 80mg Urine: Please enter the milligrams of alcohol per 100 millilitres of urine. The legal limit is 107mg

Have you been convicted of any non-motoring offence(s)?*

Yes
No

Additional Drivers

Additional Driver 1 Details

Title*

First Name(s)*

Surname*

Gender*

Male
Female

Date of Birth*

Have they been a permanent resident of the UK since birth?*

Yes
No

When did they become a UK resident?*

Marital Status*

Their relationship to the policy holder*

What type of driving licence do they have?*

When did they obtain their licence?*

Do they personally have access to any other vehicles?*

Have they ever been refused car insurance, or ever had an insurance policy voided or cancelled?*

Yes
No

Do they have any medical conditions that affect their driving?*

Yes
No

Have the DVLA been notified of their medical condition?*

Yes
No

Telling DVLA about a medical condition or disability

You must tell DVLA if you have a driving licence and:

you develop a ‘notifiable’ medical condition or disability
a condition or disability has got worse since you got your licence

Notifiable conditions are anything that could affect your ability to drive safely. They can include:

epilepsy
strokes
other neurological and mental health conditions
physical disabilities
visual impairments

You could be fined up to £1,000 if you don’t tell DVLA about a condition that might affect your ability to drive safely. You could also be prosecuted if you have an accident.

By phone

DVLA drivers’ medical enquiries
Telephone: 0300 790 6806
Monday to Friday, 8am to 5:30pm
Saturday, 8am to 1pm

What is their employment status?*

What is their occupation?*

Please enter your job description. This will generate a list from which you can select the most appropriate description. For example: If you work in a call centre, you should enter Telesales Person or Customer Advisor. NB: If you have entered only part of your job description and you are unable to find your job in the list, please enter more characters to refine the list.

What is their employer's business? e.g. Retailing*

Please enter a description of their employer's general area of business. This will generate a list from which you can select the most appropriate description. For example: If they work in a high street shop, you should enter Retailing. NB: If you have entered only part of their employer's business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Their business type*

Please enter a description of their general area of business. This will generate a list from which you can select the most appropriate description. For example: If they work in a high street shop, you should enter Retailing. NB: If you have entered only part of their business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Line of Business*

Please enter a description of their general area of business. This will generate a list from which you can select the most appropriate description. For example: If they work in a high street shop, you should enter Retailing. NB: If you have entered only part of their business and you are unable to find the correct business in the list, please enter more characters to refine the list.

Do they have a Part-Time or an Additional Job?*

Yes
No

What is their part-time employment status?*

What is their part-time occupation? e.g. Sales Manager, Computer Programmer or Plumber*

About the vehicle

Use of the Car

Your Policy

Your Personal Details

Contact Information

Employment Information

Part-time Employment Information

Your Driving

Telling DVLA about a medical condition or disability

Claims and Convictions

Additional Drivers

Additional Driver 1 Details

Telling DVLA about a medical condition or disability