BASICS Scheme

Proposer details

* Title:

* First names:

* Last name:

* Email address:

Date of birth: D: M: Y:

Address at which the vehicle is normally kept:

Postcode:

Daytime tel no:

Home tel no:

Trading name:

Medical liability: YesNo

Age of driver:

Do you have a convictions history (within last 5 years): YesNo

If you ticked yes, you must fill in the section below:

Date: D: M: Y:

Code:

Points (No):

Ban Mths:

Fine:

Vehicle details

Full details of make and model:

Registration Number:

Year of registration:

Fuel type: DieselPetrol

Transmission: ManualAutomatic

Modifications / further information:

Security measures, if any:

Additional driver details

Name of additional driver:

Date of birth: D: M: Y:

Cover & use

What cover is required?:

Voluntary excess required?: £100 Excess£150 Excess

Preferred amount:

With or without contents?: WithWithout

Value of contents:

Do you have a claims history (within 5 years)?: YesNo

Date: D: M: Y:

Details of loss:

Amount:

Period of insurance:

Date insurance to commence:

By providing your email address, you are happy to allow contact from the advertiser about your query.