| PERSONAL
DETAILS |
| Title |
|
| Surname |
|
| Christian
name |
|
| Gender |
M
F
|
| Marital
status |
|
| Date
of birth |
|
| Postal
Address |
|
| Post
code |
|
| E-mail
address |
|
| Contact
telephone number |
|
| Occupation |
|
| Employer's
business |
|
| When
would you like cover to start |
Straight away
In the next week
2+ more weeks |
| Part
Time Occupation (if any) |
|
| MOTORBIKE
DETAILS |
| Type
of vehicle |
Bike
Moped / Scooter
Quad (must be road legal)
Trikes (must be road legal) |
| Type
of motorcycle driving licence |
|
| Date
passed bike test |
|
| Make
of bike |
|
| Exact
model |
|
| Engine
size |
|
| Year
of manufacture |
|
| Value |
£
|
| Registration
Number |
|
| Storage
arrangements |
|
| Make
of alarm/immobiliser (if none, state none) |
|
| Datatag |
Yes
No
|
| Is
the vehicle registered in your name? |
Yes
No
|
| If
'NO', please give the owners name |
|
| Please
give details of any claims, convictions or pending prosecutions |
|
|
COVER DETAILS |
| Cover |
|
| Use |
|
| Total
annual mileage |
|
| Number
of years BIKE No Claims Bonus |
|
| Do
you require protected No Claim Bonus? |
Yes
No
|
| ADDITIONAL
DRIVER DETAILS |
Please
give FULL details of additional driver(s)...see
below.
PLEASE
NOTE THAT WE NEED THE FOLLOWING:
Name, date of birth, occupation, details of any convictions,
accidents and whether or not they have access or own any
other vehicles, type of licence (i.e full, provisional),
relationship to you (I.e. spouse, son/daughter) and how
long they have had the licence for. |
|
|
