Tractor Insurance - Quotation Request
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Proposer's Name |
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E-mail address (required) |
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Address |
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Postcode |
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Telephone No |
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Fax No (optional) |
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Contact Name |
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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? |
Yes
No
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or been declared Bankrupt or Insolvent? |
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? |
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) |
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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Tractor Details |
| Make and model/type |
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Year of manufacture |
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Estimated value (£) |
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Registration mark or Identification No |
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NCD (years) at this renewal |
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| Cover required |
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| Will the tractor be garaged or fitted with an alarm, immobilizing, tagging or tracking device |
Yes
No |
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Further
information |
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Are any of the above vehicles owned by anyone other than
you? |
Yes
No |
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if 'yes' please state vehicle numbers |
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Will any of the vehicles be used for any purpose other
than farming or small holding? |
Yes
No |
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Driver details |
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To the best of your knowledge will the vehicle 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? |
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? |
Yes
No |
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c) has had a licence suspended during the past 5 years? |
Yes
No |
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d) is under 21 or over 79 years of age? |
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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| Main Occupation |
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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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| Main Occupation |
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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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| Main Occupation |
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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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| Main Occupation |
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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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| Main Occupation |
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Additional info |
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Claims Experience |
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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? |
Yes
No |
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b) imposed special conditions (e.g. premium loading, cover
restrictions or increased excess)? |
Yes
No |
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if you have answered yes to any of the above
please give details |
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| Other Information |
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Renewal date of present insurance (if applicable) |
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| Name of Insurer |
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| Other insurances due on... |
| Farm |
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| Household |
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| Business |
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