SPECIAL TYPE VEHICLE INSURANCE QUOTATION

PROPOSER

Name
T/as
Trade
Trading Since Terrirtory

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
(02)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(03)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(04)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(05)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(06)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(07)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(08)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(09)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(10)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(11)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(12)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(13)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(14)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk
(15)        
Reg/Serial Type Make/Model Year Value
Alarm Modified Seats Cover Working Risk

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
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
2
3
4
5
Continued...    
Sec B Licence Type Yrs Held Clean Licence
1 ( )
2 ( )
3 ( )
4 ( )
5 ( )
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