Motor Traders Combined Insurance - Quotation Request

Name of Proposer

E-mail address

Trading as

Address of premises

Postcode

Telephone No

Fax No (optional)

Insurance required from

Road Risks

Is this cover required?

Yes No

if 'no' please click here, if 'yes' please complete this section

Please select scope of cover required

select >>> Comprehensive Third Party Fire and Theft Third Party Only  

Policy excess required

select >>> £100 £150 £200 £250 other amount  

if 'other' please insert amount

Driver details

To the best of your knowledge will the vehicles be driven by any person who:

a) has any physical or mental defect or suffers from diabetes, epilepsy or any heart complaint?

Yes No

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?

Yes No

c) has had a licence suspended during the past 5 years?

Yes No

d) is under 25 years of age?

Yes No

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.

Driver 1

Full name

Date of birth

Date test passed

Additional info

Driver 2 or move on

Full name

Date of birth

Additional info

Claims Experience

How long have you been in business?

 years

Has any insurer in respect of any business in which you have been engaged ever:

a) declined a Proposal, not invited a renewal of a Policy, refused to renew or cancelled a Policy?

Yes No

b) imposed special conditions (e.g. premium loading, cover restrictions or increased excess)?

Yes No

Further Information

For which motor manufacturer(s) are you a main or sub-dealer? (if none, please state 'none'

Are you a member of any motor trade association(s)?

Yes No

if 'yes' which one(s)

Do you specialise in selling, repairing or servicing:

1) Sports cars, high performance cars or cars with a market value in excess of £20,000

Yes No

2) Veteran, vintage or classic vehicles

Yes No

3) Commercial or public service vehicles?

Yes No

4) Agricultural vehicles or implements?

Yes No

Has the proposer or any Partner or Director ever been:

a) Convicted of or charged (but not yet tried) with a criminal offence?

Yes No

b) Declared Bankrupt or Insolvent?

Yes No

Renewal date of present insurance
(if applicable)