westcraveninsurance.com
Please complete the details below as fully as possible.
Client's name:
Email address:
Home address:
Postcode:
Date of birth: D: M: Y:
Home phone:
Base office name:
Base address:
Base phone:
Licencing authority:
Make & model:
Engine cc:
Date purchased: D: M: Y:
Fuel type: Petrol Diesel
Year of manufacture:
Value:
Annual mileage:
VPlated passengers:
Hours used per week for business:
What cover is required?: ComprehensiveThird PartyFire & TheftThird Party Only
Private HirePublic HireBoth
Badge held since: D: M: Y:
Is vehicle subject to any HP in insured's name? Yes No
Do you have a convictions history (within last 5 years): Yes No
Date: D: M: Y:
Code:
Points (No):
Ban Mths:
Fine:
Do you have a claims history (within 5 years)?: Yes No
Details of loss:
Amount: