Sam Car Insurance Form

What is The Registration? *

What is The Registration?

What is The Car Value? *

What is Car Value?

Do you have the car yet? *

Yes

No

How do you want to use the car? *

Social Only

Social & Commuting

Business use by you

What type of cover do you need? *

Full comprehensive

3rd party, fire & theft

3rd party only

Personal Information

What is your title? *

Your First Name: *

Your Last Name: *

Date of Birth: *

Material Status: *

Do you have any under 16 years old children?

House or street number and name : *

Postcode: *

What is your job?: *

When did you start living in UK? *

Since Birth

From Date

License Information

What is your License type? *

Date of Pass: *

Your license number: *

Did you have any accidents (fault or non-fault), Theft, Fire, Storm, Flood or vandalism damage in the last 5 years? *

Yes

No

Add 1st Accident:

What kind of incident or claim was it? *

Incident Date:

Total Claim Cost:

Do you want to add another accident?

Yes

No

Did you have any points or disqualification in the last 5 years? *

Yes

No

1st Offence:

What is the DVLA offence code?

When did the Offence happen? *

Points incurred:

Did you pay a fine?

How many months were you banned?

Do you want to add another offence?

Yes

No

What is the DVLA offence code?

When did the Offence happen?

Points incurred:

Did you pay a fine?

How many months were you banned?

Do you have any No Claim Bonus Discount? *

Yes

No

When would you like your insurance to start? *

Mobile Number *

Your Email Address: *

Do you want to Add 2nd Driver?

Do You Have Something else to Tell Us

I confirm that the details i provided are correct and responsible for any incorrect information.

Sam Car Insurance Form

What is The Registration? *

What is The Car Value? *

Do you have the car yet? *

How do you want to use the car? *

What type of cover do you need? *

Personal Information

When did you start living in UK? *

License Information

Did you have any accidents (fault or non-fault), Theft, Fire, Storm, Flood or vandalism damage in the last 5 years? *

Add 1st Accident:

Did you have any points or disqualification in the last 5 years? *

1st Offence:

Do you have any No Claim Bonus Discount? *

Do you want to Add 2nd Driver?

2nd Driver Details:

Did They have any accidents (fault or none fault), Theft, Fire, Storm, Flood or vandalism damage in the last 5 years ? *

Add 1st Accident:

Add 2nd Accident:

Did They Have any points or disqualification in the last 5 years? *

1st Offence :

2st Offence :

Do You Have Something else to Tell Us