Your Details:
Full Name:
Email Address:
Telephone Number:
Mobile Number:
Address Line 1:
Address Line 2:
Post Code:
The Policy:
Desired Policy Start Date:
(dd/mm/yyyy)
Your No Claims Bonus:
None
1 Year
2 Years
3 Years
4 Years
Over 5 Years
Current Premium (in £'s):
Who will drive the vehicle?:
Any Driver
Insured and Named Drivers
Insured only to Drive
Level of cover required:
Fully Comprehensive
Third Party Only
Third Party, Fire & Theft
The Vehicle:
Vehicle Make:
Vehicle Model:
Is the gross vehicle weight under 3.5 tonne?
Yes
No
Do you use your vehicle for courier or haulage work?:
Yes
No
Where is your vehicle stored:
Please Select
Public Car Park
Private Carport
Garaged
In a Locked Building
In a Locked Compound
Parked on a Private Drive
Parked on Private Property
Parked on a Public Road
Named Drivers:
Date of Birth of Main Driver:
(dd/mm/yyyy)
Has the insured or any named driver had any motoring convictions in the last 5 years:
Yes
No
Has the insured or any named driver had any accidents or claims in the last 3 years:
Yes
No
Do the insured or any named driver have any disabilities:
Yes
No
Has the insured or any named driver ever been refused insurance:
Yes
No
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.
Macclesfield Insurance Services Ltd is authorised and regulated by the Financial Services Authority No.417382
