Motor Insurance

Fill out this form if you would like us to give a quote for your car insurance. When you've filled in as much as you can, send the form to us by clicking on the SUBMIT FORM TO SR INSURANCES button.

Proposer / Policyholder
Title

Forenames

Surname

Address

Postcode (this is essential to enable us to provide a quotation)

Home Telephone Number

Work Telephone Number

E-mail address

Fax Number

Date of Birth (eg 27/04/1963)

Marital Status

About your work…
Employment Type

Occupation

Full or Part time?

Employer's Business

Type of Driving Licence

Number of years you have held licence

Date or year you passed your driving test (dd/mm/yyyy)

Are you a smoker?

Vehicle Details
Make

Model - exact type

Style

When did you purchase this vehicle (dd/mm/yyyy)

Gearbox

Fuel

Engine Size (cc)

Drive side

Is the vehicle normally garaged?

Value of the vehicle

Has the vehicle been modified?

If 'Yes', please give brief details

Type of Alarm / Immobiliser (if fitted)

Total annual mileage

Business mileage

Year of Manufacture

Registration Number

Postcode where the vehicle is kept (postcode is essential to enable us to provide a quotation)

Use and Cover
Main purpose of use

Level of cover required

Voluntary Excess

Who is going to drive the vehicle? How many years No Claims Bonus?

Do you require No Claims Bonus Protection?

How many years with this company?

When does your current policy expire? (dd/mm/yyyy)

Date you require cover to start (dd/mm/yyyy)

Additional Driver
Age of youngest additional driver

Relationship to the proposer?

Do they own or use another car?

Title

Forenames

Surname

Employment Type

Occupation

Full or Part time?

Date of Birth (dd/mm/yyyy)

Type of Driving Licence

Number of years licence held

Date Driver 2 passed their driving test (dd/mm/yyyy)

Is Driver 2 a smoker?

Driver Declaration
Has either the proposer or Driver 2 had any motoring convictions in the past five years or is any prosecution pending?

** All drink / drug related ("DR") convictions within the last 11 years must be disclosed. The date entered below should be the date of the conviction.

Conviction 1 Code

Date (mm/yyyy)

Ban (months)

Points on Licence

Fine (£)

Conviction 2 Code

Date (mm/yyyy)

Ban (months)

Points on Licence

Fine (£)

Conviction 3 Code

Date (mm/yyyy)

Ban (months)

Points on Licence

Fine (£)

Conviction 4 Code

Date (mm/yyyy)

Ban (months)

Points on Licence

Fine (£)

Has any of the proposed drivers suffered from any medical conditions or disability which affects their driving?

Has any of the drivers benn declined motor insurance?

Do you have any other convictions?

If you answered 'Yes', please give further details

Has either the proposer or Driver 2 had any accidents or claims in the last three years?

Type of claim - please give details including date and cost of the claim

And finally…
Who do you insure the vehicle with at present?

What is the renewal date of your present policy?

Is there anything else you need to tell us about?

How did you hear about this web site

The personal details you have submitted on this form will be used only for the purposes of supplying you with a quotation. None of this information will be made available to other companies or organisations for the purpose of mailing, promotions, direct selling or any other offers.

Thank you for filling in this form. Please ensure you have filled in as much as possible - the more details you give us the better quote we can give you!

For you own records you may like to have a printed copy of this form. Just press the Print Form button.
Press the SEND button to forward your details to us.

We will forward a quote as soon as possible.

Back to Motor Insurance

Sharpley & Regent Insurance Services Ltd.
38 Alexandra Road, LOWESTOFT, NR32 1PW
Tel: 0845 130 0202 (Calls charged at local rate)
Fax: 01502 532605

ã Sharpley & Regent Insurance Services Ltd. 1999 - 2007