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Full Name
Date of Birth
Full Address
Policyholder
Driver 2
Vehicle
Registration Number
Vehicle Make & Model
Date Purchased / Will be Purchased / Cover Needed From
Value
Vehicle Kept at Postcode
Parking Location overnight when not in use i.e., garaged, parked on drive?
Parking Location during the day
Registered Owner (if company, please provide name)
Registered Keeper (if company, please provide name)
Usage Required (SDP & Commuting, Business etc)
Annual Mileage
Any Modifications?
What is your target premium/quoted elsewhere?
Licence Type and Date Test Passed e.g., Full UK & (dd/mm/yyyy)
Years resident in the UK
Marital Status
Occupation
Business (field of employment)
Other vehicles currently in the household/owned
Recent vehicles owned and driven (enables us to understand your driving history i.e. make & model)
Have you (or, any named driver) ever had insurance refused or cancelled?
Medical Conditions notifiable to the DVLA
Driving convictions in the past 5 years (date, code, points and fine)
Accidents & Claims in the past 3 years (date, circumstances, liability and amount paid if known)
Years NCB
Would you like your NCB protected (Y/N)
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