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Motor Insurance Quote Form
Please complete the following with as much information as possible! *required
*Forenames:
*Your surname:
*Address where vehicle is kept:
*Postcode:
*Tel no.
*Email address:

Date cover required from:   Select Date
Date of birth:
Day Month Year (e.g. 1980)
Renewal date of your current policies:   Select Date
Gender:
Male Female
Marital Status:
Single
Who drives?
1. Insured only driving
2. Named drivers
3. Insured and spouse
4. Any licensed driver

  Date of birth Date full licence obtained Occupation % of use Do they have their own car?
Proposer
Yes No
Spouse/partner
Yes No
Additional driver 1
Yes No
Additional driver 2
Yes No

Class of use:
 
Social domestic and pleasure Social domestic and pleasure plus commuting  
Personal business Employers business  

About the vehicle:
Make Model Engine size (cc)
Gearbox Type:
Manual Automatic  
Fuel Type:
Petrol Diesel  
Registration details:
Month Year (e.g. 1980)
Value:
£  .00
Kept at night:
1. In garage 2. On driveway 3. On street
Cover required:
1. Comprehensive 2. Third party and theft 3. Third party only
Current insurer:
Expiry date:
No claims bonus:
Yes No If Yes how many years?

Is this protected?

Yes No
Regular use of another car?
Yes No
Any medical conditions notified to the DVLA:
List claims details separately (dates, payments and circumstances)
List convictions separately
(dates fines and codes)


  Terms of Business    
© 2008 H R Jennings & Co Limited are authorised and regulated by the Financial Services Authority
Registered address: 21 Buckle Street, London E1 8NN