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Title:* |
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| First
name:* |
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| Surname:* |
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| Email
address: * |
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| Contact telephone
number:
* |
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| Mobile number (if different):
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| Address:
* |
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| Postcode:
* |
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| Occupation:
*
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| Total number of vehicles in
household:
* |
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| Licence Details: |
| Licensing
authority:* |
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| Is the council vehicle licence in your
name?* |
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| Number of passengers you are licenced to
carry:* |
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| Type of licence:* |
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| Base office postcode:* |
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| Vehicle make:
*
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| Vehicle model & model type:
*
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| Include full details of
model, e.g. GTi, TDi, GSi etc
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| Body type:* |
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| Engine size (cc):
*
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| Transmission type: *
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| Number
of seats:* |
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| Fuel type:* |
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| Year of make: *
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| Market value: *
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Registration number:
* (Please state if
unknown)
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| Cover required: *
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| Who
will be driving the vehicle?* |
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| Full postcode of where vehicle is normally kept overnight:
(if different to home
postcode)
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| Where is the vehicle parked overnight:
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| Estimated annual mileage
:
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| Driver Details |
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| Main driver |
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| Are no claims to be protected?* |
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Have you had any motoring
accidents or losses in the past 5 years?*
If yes, please provide
details: |
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Date (s):
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Description:
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Amount (s)
paid £
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Have you had any motoring
convictions at any time?*
If yes, please provide
details: |
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| + Additional Driver 1 |
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| + Additional Driver 2 |
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| + Additional Driver
3
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| Your Enquiry |
| Date cover to start / renewal date:
* |
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| Current motor insurance
provider: *
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Current motor insurance premium (if
none please state) : * |
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NB: cover is
not in force until agreed upon by the company |
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| Contacting
You |
| Preferred contact method:
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| Preferred contact time:
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| How did you hear about
us? |
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Towergate Risk Solutions is a trading name of Towergate Underwriting Group
Ltd. We would like to contact you from time to time about
products and services (or with news, offers, services and promotions) that
we feel may be of interest to you. By providing us with your contact details, you
consent to being contacted by these methods for these
purposes.
Please tick the box if you prefer not to
receive marketing communications from us by post or telephone.
Please tick the box if you prefer
not to receive marketing communications from us by email,
text messaging or other electronic means. |
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