Please complete all the details required below Your Details Title Mr Mrs Miss Ms Dr    Name Trading Name Address Postcode Email address Tel No Full time occupation Part time occupation Activity in motor trade Years Trading Trading From Home Premises   Road Risks Cover Details of all persons who will drive including yourself: eg. NAME - AGE - YRS FULL LICENCE - PROPRIETOR / SPOUSE / EMPLOYEE Has Anyone Who May Drive:-   Been convicted of any driving offence in the last five years No Yes Been disqualified in the last 10 years No Yes eg. NAME - CONVICTION CODE - CONV DATE - POINTS - DISQUALIFIED Y/N - LENGTH OF BAN Any disease, disability or infirmity No Yes eg. NAME - DISEASE - DISABILITY - INFIRMITY Been involved in any motor claim in the last three years No Yes eg. NAME - ACCIDENT/LOSS DATE - FAULT/NON FAULT ACCIDENT OF THEFT - AMOUNT CLAIMED Have you or and one disclosed ever been convicted of, or charged (but not yet tried) with a criminal offence No Yes eg. NAME - DETAILS OF CONVICTION List all vehicles owned and used by you for your personal or business use.   eg. VEHICLE MAKE & MODEL - YEAR - VALUE Do you operate a recovery vehicle No Yes If yes then enter details eg. RECOVERY VEHICLE MAKE & MODEL - YEAR - VALUE   Type Of Trade Do you specialise in the following: Prestige, Sports or high performance vehicles Veteran, Vintage or Classic Vehicles Commercial Vehicles over 3.5 tonnes Public Service Vehicles Motorcycles Cover required Comprehensive Third Party Fire & Theft Third Party Only Indemnity Level required (Max vehicle value) How many years No-Claims-Bonus Trade Private     Additional Covers Additional Covers - Stock of vehicles required No Yes Number of vehicles Single vehicle value Total vehicle value Internal or Garage Risks Required No Yes Buildings Fixed Plan & Machinery Portable Tools Stock Business Interruption Required No Yes Gross Proffits Goods in Transit Required No Yes Sums Insured To include vehice transport No Yes Money Required No Yes Wrongful Conversion Required No Yes Sums insured (min £5,000) Public Liability Required No Yes Employers Liability Required No Yes Defective Workmanship / Sales Indemnity Required No Yes   Inorder to calculate the premiums for the liability sections we require the following information: Projected approximate annual turnover Projected approximate annual wages roll Have you made a claim in respect of the above in the last 3 years No Yes

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FSA Reference number is 450429

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