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Motor Insurance Quotation Form
 
Main Driver / Policyholder
 
Title:
First name:*
Surname:*
 
Address line 1:*
Address line 2:*
Town or city:*
Postcode:*
 
Daytime Contact Number:*
Mobile Number:
Email Address:
 
Date of Birth:*
 
Type of License:
How Long License Held:*
Driving Status:
 
Marital Status:*
 
Any Accidents / Claims / Convictions in past 5 years:
 
If yes, please elaborate (for accidents we need dates, driver, circumstances, fault or non fault, costs for own damage, costs for 3rd party, any injuries...For convictions we need dates, codes, fine, points, alcohol level, length of any disqualification):
 
Occupation:*
 
Annual Mileage:*
 
Any access to other cars:
 
Any Criminal Convictions / Bankruptcy / CCJs Insurance declined:
 
If yes, full details are required:
 
 
Additional Drivers - If none, please skip this section
 
Additional Driver 1
 
First name:
Surname:
Title:
 
Date of Birth:
 
Type of License:
How Long License Held:
Driving Status:
 
Marital Status:
 
Any Accidents/Claims/Convictions in past 5 years:
 
If yes, please elaborate (for accidents we need dates, driver, circumstances, fault or non fault, costs for own damage, costs for 3rd party, any injuries...For convictions we need dates, codes, fine, points, alcohol level, length of any disqualification):
 
Occupation:
 
Annual Mileage:
 
Any access to other cars:
 
 
Additional Driver 2
 
First name:
Surname:
Title:
 
Date of Birth:
 
Type of License:
How Long License Held:
Driving Status:
 
Marital Status:
 
Any Accidents/Claims/Convictions in past 5 years:
 
If yes, please elaborate (for accidents we need dates, driver, circumstances, fault or non fault, costs for own damage, costs for 3rd party, any injuries...For convictions we need dates, codes, fine, points, alcohol level, length of any disqualification):
 
Occupation:
 
Annual Mileage:
 
Any access to other cars:
 
 
Additional Driver 3
 
First name:
Surname:
Title:
 
Date of Birth:
 
Type of License:
How Long License Held:
Driving Status:
 
Marital Status:
 
Any Accidents/Claims/Convictions in past 5 years:
 
If yes, please elaborate (for accidents we need dates, driver, circumstances, fault or non fault, costs for own damage, costs for 3rd party, any injuries...For convictions we need dates, codes, fine, points, alcohol level, length of any disqualification):
 
Occupation:
 
Annual Mileage:
 
Any access to other cars:
 
 
Vehicle
 
Make:*
Model:*
Type:
Engine Size:*
Registration number if known otherwise year of manufacture:*
Value (to the nearest round number):*
Number of Doors:
Number of Seats:
Purchase Date
Security Details (any alarms, immobilisers etc):
Parking:
Any Modifications (full details required):
 
 
Cover
 
Type of Cover:
How many years no claims:*
Protect your no claims bonus?
Class of use:


Pavey Group is a trading style of Michael Pavey Ltd which is authorised and regulated by the Financial Services Authority. It's FSA registration no. is 308106. Pavey Group is also a trading style of Michael Pavey Financial Services Limited which is authorised and regulated by the Financial Services Authority. It's FSA registration number is 463257. You can check this on the FSA's Register, by visiting the FSA's website on www.fsa.gov.uk/register or by contacting the FSA on 0845 606 1234.

 

Michael Pavey Ltd. (Registered in England 3419086) and Michael Pavey Financial Services Ltd (Registered in England No. 3418320) are subsidiary companies of Michael Pavey Holdings Ltd (Registered in England No. 02979493). Our registered Address: 50 The Terrace, Torquay, Devon, TQ1 1DD.

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