Your Details:
Full Name:
Date of Birth:
(dd/mm/yyyy)
Address Line 1:
Address Line 2:
Post Code:
Email Address:
Home Telephone:
Mobile Telephone:
The Vehicle :
Make/Model:
(eg. Ford Fiesta)
Body Type:
Caravanette
Convertible Saloon
Convertible Sport
Convertible/Cabriolet
Coupe
Estate Car/Station Wagon
Hatchback
Jeep
Light Van
Motor Caravan
People Carrier
Pick-up
Saloon
Van
None of the Above
Engine Size:
(eg. 1.3)
Year:
(yyyy)
Value:
Number of Doors:
Registration:
Name of Vehicle Owner:
Name of Vehicle Keeper:
Further Details:
Immobiliser?
Yes
No
Thatcham?
1
2
Neither
Vehicle Modified?
Yes
No
Vehicle Imported?
Yes
No
Right / Left Hand Drive?:
Right
Left
Overnight Location:
Road
Garage
Driveway
Post Code of Location:
Your Policy:
Level of Cover Required:
Third Party Only
Third Party Fire and Theft
Comprehensive
Vechicle Use:
Social, Domestic and Pleasure
Social, Domesitc and Please inc. Commuting
Business Class 1
Business Class 2
Business Class 3
Mileage per Annum:
No Years Claim Bonus:
(0-9)
Previous Insurer:
(if none, leave blank)
Protected No Claims Required?:
Yes
No
Driver Details:
Policy Holder
Driver One (Optional)
Driver Two (Optional)
Full Name:
Date of Birth:
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
Place of Birth:
UK Residency:
Gender:
Male
Female
Male
Female
Male
Female
Marital Status:
Married
Married - Common Law
Divorced
Not Applicable
Partnered
Separated
Single
Widowed
Married
Married - Common Law
Divorced
Not Applicable
Partnered
Separated
Single
Widowed
Married
Married - Common Law
Divorced
Not Applicable
Partnered
Separated
Single
Widowed
Full Time Occupation:
Part Time Occupation:
License Type
(eg Full UK)
Length Held:
Relationship to Policy Holder:
Access to Other Vehicles:
Disabilities:
If the answer is 'none' then leave the field blank for the above.
Convictions:
Driver Name
Date of Conviction
Conviction Code
Fine
No. Points
Ban Length
If the answer is 'none' then leave the field blank for the above.
Accidents/Thefts or Losses:
Driver Name
Date of Accident
Description
Cost
Personal Injury
NCB Affected?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If the answer is 'none' then leave the field blank for the above.
Macclesfield Insurance Services Ltd is authorised and regulated by the Financial Services Authority No.417382
