Seico Insurance Consultants

Main Driver Details:

Title:(Mr, Mrs, Ms, Miss)
Full Name:
Address
Town/City:
County:
Country:
Post Code:
Are you Currently a Home Owner:
Home Telephone:
Work Telephone:
Mobile Phone:
Telephone Call back Instructions:
E-mail Address:
Date of Birth (dd/mm/yy)
Sex:
Marital Status:
Main Occupation:
Is this Full / Part time?
Other Occupation:
Employers Business:
Driving licence type:
Number of years since passing test
Number of years resident in UK
Is the proposer a smoker?

Vehicle Details:
Manfacturer:
Model:
Version:
Engine Size:
Fuel type:
Transmission Type:
Right-Hand Drive:
Number of doors:
Number of seats:
Year of Manfacture: View Registration Year List
Registered in the UK
Registration number:
Date of Purchase(dd/mm/yy)
Current value (UKPounds)
Current Mileage:
Estimated annual mileage:
Estimated annual business mileage:
Car kept at the address above:
If no please give details:
Postcode:
Usually parked at night:
Usually parked during the day:
Vehicle owner:
Vehicle Keeper:
Number of vehicles in household:
Vehicle has been modified:
If yes then give details:
Vehicle alram, immobiliser or other anti-theft device fitted:
If yes then please give details of makes, models and dates fitted:
Vehicle fitted with ABS:
Cover Details:
Start date of cover(dd/mm/yy)
Cover required:
Vehicle use:
Who will Drive:
Insurance company which held your vehicle insurance last year:
Best alterantive/ renewal quote (UK pounds):
Number of years of no claims bonus:
Protected no claims discount required:
Any special requirements or information not dealt with above:
Other Drivers:
*Driver 2* (if applicable)
Relationship to proposer:
Own another car:
Title (Mr/Miss/ Mrs/Ms):
Full Name:
Date of Birth(dd/mm/yy)
Main Occupation:
Other Occupation:
Is driver a smoker?:
Driving Licence type:
Number years holding a full licence:
Vehicle use:
*Driver 3* (if applicable)
Relationship to proposer:
Own another car:
Title (Mr/Miss/ Mrs/Ms):
Full Name:
Date of Birth(dd/mm/yy)
Main Occupation:
Other Occupation:
Is driver a smoker?:
Driving Licence type:
Number years holding a full licence:
Vehicle use:

Driving Record:
Have you or any person to your knowledge who will drive the vehicle:	1.Ever had any motor insurance cancelled, refused or renewal refused 2.Been asked to pay an increased premium (other than normal rating increases) or had special conditions imposed 3.Been convicted of any motoring offence connected with drink or drugs or failure to provide a speciman or driving without insurance during the last 11 years 4.Been convicted of any other motoring offences during the last years

	If you have answered yes to the questions above please give details including the name of the driver, the offence, the amount of the fine, the number of points, date of conviction, date of offence and disqulaifcation period:

Have you or any other person to your knowledge who will drive the vehicle:	Have more than 5 current points (i.e less than 3 years old) on their licence:
	Been reported for any motoring offences or is any prosecution or police enquiry pending:
	Had any motoring accidents and/ or claims during the last 5 years: If yes, how many claims during the last 5 years and please give details including the name of driver, date, amount of claim, the circimstances and whether it was settled in your favour:

	Any physical or mental defect or infirmity or suffered from diabetes, fits or any heart complaints: If yes, please give details including the drivers name, condition, date, and when licences is valid until:



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