Non-Disclosure Warning: Please note that you are under a duty to disclose all facts likely to influence the acceptance and assessment of your proposal. Failure to do so may invalidate the insurance. It is in your own interest to mention such facts. If you are in any doubt whether certain facts are materials, please ask your Broker:
About You: |
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| Title |
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Full
Name |
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Full
Postal Address |
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Full
Work Address |
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Telephone
(Daytime) |
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Telephone
(Evening) |
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Email
Address |
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Date
of Birth |
Day
Month
Year
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Are you the Main Driver of the Vehicle |
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If the answer is “NO” please give details: |
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Will
you or anyone who will drive the car use it for
Business purposes? If so, please give details:
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Number
of claim free driving years in your own name: |
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From Year:
To Year:
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Or
Number of claim free driving years as a named driver: |
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From Year:
To Year:
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Name
of previous Insurance Company:
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Please
select which type of licence you hold?
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Renewal
date of policy: |
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Day
Month
Year
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About
Your Car |
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Is the car registered in your name |
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If the answer is “NO” please give details: |
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Make
& Model : e.g. Ford Escort 1.3L
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Engine
Capacity (cc), e.g. 1296:
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What
is year of the car?
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What
is the car registration?
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What
is the value of your car?
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Date you purchased the vehicle: |
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Day
Month
Year
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| Is the car to the makers standard specification without modification: |
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If the answer is “NO” please give details: |
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Additional
drivers:
Before completing this section you must ensure that you have any drivers consent to our use and sharing of any personal/sensitive data.
Please
complete the following details about your additional drivers:
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Driver
No. 2 |
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Full
name:
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Date
of Birth: |
Day
Month
Year
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Occupation(including part-time): |
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Relationship
to you e.g. Spouse |
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What
kind of licence do they have?
|
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Driver
No. 3 |
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Full
name:
|
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Date
of Birth: |
Day
Month
Year
|
Occupation(including part-time): |
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Relationship
to you e.g. Spouse |
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What
kind of licence do they have?
|
|
| |
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Driver
No. 4 |
|
Full
name:
|
|
Date
of Birth: |
Day
Month
Year
|
Occupation(including part-time): |
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Relationship
to you e.g. Spouse |
|
What
kind of licence do they have?
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Cover
required: Please select which type of cover you need:
Please select if you wish to avail of Protected No Claims Discount cover for an extra premium:
*see terms and conditions below for this cover.
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Have you or any person who will drive the vehicle to your knowledge:
Been disqualified from driving or convicted of any offence in connection with any motor vehicle within the last 10 years or is any prosecution pending or had any Penalty Points applied in the last 5 years?
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No.
of Points |
Type
of Offence
(please give full details) |
Date
of Points Application
(DD/MM/YY) |
Driver
No.1
(Self) |
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Driver
No.2 |
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Driver
No.3 |
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Driver
No.4 |
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If
there are any other details you feel are relevant, please fill
in the following section:
Thank you for taking the time to complete this quotation, we will respond to you by E-mail.
Data
Protection Notice
Please tick here if you wish us to contact you by post. |
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| Please
note that Cover will not commence until the Company has accepted
the details you have provided and agreed cover.
You
should ensure that the details supplied to us are true to the
best of your knowledge and belief.
AXA
Insurance Limited is regulated by the Financial Regulator |
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* Protected No Claims Discount (NCD)
A no claims discount can take years to earn, yet minutes to loose. For an additional premium, (approx.12.5% of your premium) we can now protect your No Claims Discount against one claim in a 3 year period. This discount protects your NCD against the first Third Party (TP) or Accidental Damage (AD) claim. You must be claim free for the past 3 years. You must be earning a 70% No Claims Discount on AXA’s NCD scale. |
