| Motor Fleet
Insurance - Quotation Request
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Proposer's Name
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E-mail address (required)
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Trading as
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Address
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Telephone No |
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Fax No (optional)
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Contact Name (if different from Proposer)
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Are you an existing Rowett Insurance client?
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Yes
No
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General Particulars
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1) Have you the Proposer or any Partner or Director ever
been convicted of or charged (but not yet tried) with a
criminal offence?
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Yes
No
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or been declared Bankrupt or Insolvent?
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Yes
No
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2) Have you the Proposer or any Partner or Director for
the business now being propsed or for any previous business
ever been insured for any of the risks now being proposed?
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Yes
No
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if yes please give details below of the name(s), trading
name(s) and insurer(s)
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Name(s) and trading name(s)
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Insurer(s)
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Vehicles to be insured
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Click 'move on' at any time that you have completed a section
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Vehicle 1
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 2 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 3 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 4 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 5 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 6 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 7 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 8 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 9 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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cc
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Vehicle 10 or move on
to drivers
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Make and model/type
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Year of manufacture
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Cubic capacity
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Estimated value (£)
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Registration mark
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NCD (years) at this renewal
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Has the vehicle been modified in any way?
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Yes
No
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if yes, please give details
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Driver details
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To the best of your knowledge will the vehicles be driven
by any person who:
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a) has any physical or mental defect or suffers from diabetes,
epilepsy or any heart complaint?
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Yes
No
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b) has been convicted of any motoring offence (including
fixed penalty offences) during the past 5 years, or has
a prosecution pending, other than for parking?
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Yes
No
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c) has had a licence suspended during the past 5 years?
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Yes
No
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d) is under 25 years of age?
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Yes
No
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if you have answered yes to any of the above driver questions
a-d, please provide details in the additional info box for
the driver(s) involved.
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Driver 1
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Full name
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Date of birth
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Date test passed
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Additional info
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Driver 2 or move
on
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Full name
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Date of birth
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Date test passed
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Additional info
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Driver 3 or move
on
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Full name
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Date of birth
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Date test passed
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Additional info
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Driver 4 or move
on
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Full name
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Date of birth
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Date test passed
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Additional info
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Driver 5 or move
on
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Full name
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Date of birth
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Date test passed
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Additional info
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Claims Experience
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How long have you been in business?
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years
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Has any insurer in respect of any business in which
you have been engaged ever:
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a) declined a Proposal, not invited a renewal of a Policy,
refused to renew or cancelled a Policy?
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Yes
No
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b) imposed special conditions (e.g. premium loading, cover
restrictions or increased excess)?
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Yes
No
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if you have answered yes to any of the above please give
details
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Insurance required from
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Renewal date of present insurance
(if applicable)
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Preferred Payment Method
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Motor
Fleet Insurance
