Spa Insurance Services

Please complete all the details required below.

Your Current Policy
When is your policy due?		/
What is your best quote to date?
What is the excess they are quoting?
Which insurance company quoted this?
Preferred Contact Method

Vehicle Details
Registration Number
Manufacturer (e.g. Ford)
Model (e.g. Focus)
Specific Type (e.g. LX, Zetec, Ghia, Ghia X)
Engine Size (cc)
Fuel Type
Gearbox
Number of Doors
Number of seats
Month and Year registered
Purchase Price	£
Current Value	£
When did you purchase this vehicle?
If you have just purchased this vehicle what were you driving previously?
How long did you own this vehicle?
Right-hand Drive
Is this vehicle imported?
If yes, please state country imported from
Where is the vehicle kept overnight?
Who is the owner of the vehicle?
Who is the registered keeper of the vehicle?
Is the vehicle financed?
Any Modifications
Please give details of any Modifications

Immobiliser Fitted?
Tracker Fitted?
If Security not listed please give details
Private Mileage p.a.
Business Mileage p.a.
Current Milometer reading if applicable


Cover Details
Cover Type
Who will drive
Usage
Will you carry goods in this vehicle?
What total excess do you have currently?
How many years confirmed no claims bonus?
What vehicle was this earnt on?
When does this expire?
Do you require protected no claims?
Where was this bonus earnt?
Company Car Experience Years claim free
Can you get a letter from your company?
How many years claim free will it show?
Company Car Experience - Finished
Did/Does this include private use?

Proposer Details
Your First / Last Name
Your House name/number
Postcode
Daytime Telephone Number
Evening Telephone Number
email Address
Are you going to be the main driver?
Sex
Date of Birth
Marital Status
Will you use the vehicle for commuting to and from a permanent place of work or study?
Type of Licence Held
Licence Date
Do you have access to any other vehicles in the household?
How long have you resided in the UK?
Have you completed the pass plus course?
When did you take the pass plus?
Are you a home owner?
Do you own any credit cards?
Have you ever been refused insurance, had an insurer cancel a policy or had any special terms implied?
Do you have any live criminal convictions that should be disclosed under the Rehabilitation of Offenders Act?	*if yes, we will contact you to confirm
Job Title
Industry worked in
If you have a part-time occupation please state job title and industry worked in
Have you been involved in any accidents or suffered any claims/losses in the past five years?
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?
Give brief details of the condition(s) that may affect your driving

If you require more than one driver to be insured, please provide the additional driver details below before submitting this form


Driver Details - Spouse / Second Driver
Name
What relationship are you to the Proposer?
Are you going to be the main driver?
Sex
Date of Birth
Marital Status
Will you use the vehicle for commuting to and from a permanent place of work or study?
Type of Licence Held
Licence Date
Do you have access to any other vehicles in the household?
How long have you resided in the UK?
Have you completed or considered taking the pass plus course?
When did you take the pass plus?
Are you a home owner?
Have you ever been refused insurance, had an insurer cancel a policy or had any special terms implied?
Do you have any live criminal convictions that should be disclosed under the Rehabilitation of Offenders Act?	*if yes, we will contact you to confirm
Job Title
Industry worked in
If you have a part-time occupation please state job title and industry worked in
Have you been involved in any accidents or suffered any claims/losses in the past five years?
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?
Give brief details of the condition(s) that may affect your driving


Driver Details - Third Driver
Name
What relationship are you to the Proposer?
Are you going to be the main driver?
Sex
Date of Birth
Marital Status
Will you use the vehicle for commuting to and from a permanent place of work or study?
Type of Licence Held
Licence Date
Do you have access to any other vehicles in the household?
How long have you resided in the UK?
Have you completed or considered taking the pass plus course?
When did you take the pass plus?
Are you a home owner?
Have you ever been refused insurance, had an insurer cancel a policy or had any special terms implied?
Do you have any live criminal convictions that should be disclosed under the Rehabilitation of Offenders Act?	*if yes, we will contact you to confirm
Job Title
Industry worked in
Have you been involved in any accidents or suffered any claims/losses in the past five years?
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?
Give brief details of the condition(s) that may affect your driving

Driver Details - Fourth Driver
Name
What relationship are you to the Proposer?
Are you going to be the main driver?
Sex
Date of Birth
Marital Status
Will you use the vehicle for commuting to and from a permanent place of work or study?
Type of Licence Held
Licence Date
Do you have access to any other vehicles in the household?
How long have you resided in the UK?
Have you completed or considered taking the pass plus course?
When did you take the pass plus?
Are you a home owner?
Have you ever been refused insurance, had an insurer cancel a policy or had any special terms implied?
Do you have any live criminal convictions that should be disclosed under the Rehabilitation of Offenders Act?	*if yes, we will contact you to confirm
Job Title
Industry worked in
Have you been involved in any accidents or suffered any claims/losses in the past five years?
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?
Give brief details of the condition(s) that may affect your driving