Insurance Form

First Name

Middle Name

Surname

First Line of Address

Second Line of Address

Town

Post Code

Home-Owner or Rent

Telephone

Email

Marital Status

Date of Birth

UK Resident Since

UK Test Pass Date

UK Licence Number

NI Number

Start Date

Policy Type

Council

Hackney or Private Hire

Taxi Badge Pass Date

Radio Circuit or Uber

Points on Licence in last 5 years?

Public Liability needed

Yes No

No Claim Bonus Earned on Taxi?

Yes No

No Claims Bonus

Vehicle Registration Number

Vehicle Make

Vehicle Model

Vehicle Value

Vehicle Colour

Miles Per Year

How Many Passengers are You Licensed to Carry

Overnight Parking Address

Road Drive Car Park

Camera (Hardwired)

Yes No

Are You the Legal Vehicle Owner?

Yes No

Vehicle Purchase Date

Leasing/Rental Company Name

Claims in last 5 years? (fault or non-fault)

Yes No

Claim 1 Date

Fault or Non-Fault

Estimated Cost

Claim 2 Date

Fault or Non-Fault

Estimated Cost

Claim 3 Date

Fault or Non-Fault

Estimated Cost

Medical Condition (referable to DVLA)

Yes No

Criminal Convictions

Yes No

CCJ, IVA, Bankruptcy

Yes No

Insurance Refusals

Yes No

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