WBM Insurance

PRIVATE CAR INSURANCE

Please fill all the required fields!

1. You, the proposer

Title (Mr/Mrs etc.) and first name(s) Surname

Address (Including Post Code) Postcode

Daytime Tel No. Evening Tel No. Fax No.

2 Driver Details - All Drivers Must be shown

Full Name	DOB	Age	Precise Occupation both Full and Part Time	Business of Employer State if self-em&oyed	Type of licence Date UK/EU Full/Prov Driving test UK/EU, Other passed	No of Yrs driving exp. in UK	Main User

Show driving restriction required: Ins. Only Ins. & Spouse Named Drivers Any Driver

If Any Driver please state LLi age of youngest driver

3. Driver History :- Have you or any person who will drive the vehicle:

A) within the last 5 years been convicted of a motoring offence or is any endorsement pending in relation to a fived penalty notice or any other police prosecution pending'?	Yes No
B) ever been disqualified from driving or had a driving licence suspended or revoked	Yes No
C) ever been refused motor insurance, had a motor policy cancelled or any terms imposed	Yes No
D) a norifiable condition not notified to DVLA or any condition for which DVLA have restricted the licence	Yes No
E) within the last 3 years been involved in any accident or loss including theft or attempt thereat, whether to blame or not, with any motor vehicle (including motorcycles) either owned or driven?	Yes No
F) ever been convicted of any offence other than a motoring offence or is any prosecution pending?	Yes No

If answer to 3 A, B, C , D or F is Yes, give details :

Name of driver	Date of conviction or onset of condition	Offence Code	Fine imposed	Details

If answer to 3 E is Yes, give details :

Date of incident	Name of Driver or person in charge	Payments or estimated cost of claim		Brief details of each occurrence including any inluries.
		Own veh. damage	Third party

4. Vehicles Details :- This section must be completed

Make & Model	Type eg:- (L, GL etc.)	Engine capacity	No. of seats	Year of manufacture	Date of purchase	Purchase price	Current estimated value	Registration number	Value of audio equipment. State if manufacturers standard

5. Is the vehicle owned by you and registered in your name? If NO, give full details	Yes No
6. Has the vehicle been modified from manufacturer's standard specification? If NO, give full details	Yes No

7. Give the following details about where the vehicle is normally kept when not in use.

Registration number	Tick if NOT garaged	Garage Address	Distance to nearest private house	No. of vehicles normally kept I in garage

8. Give details of security devices fitted to the vehicle eg. Alarms/Immobilisers(Please Indicate if Thatcham approved)

9. Do you own or have REGULAR use of any other motor vehicle? If Yes, give full details	Yes No
10. Have you previously been insured in respect of a motor vehicle'?	Yes No
If YES, provide following information:- Name of Previous Insurer
Policy No Telephone No
Number of years No Claim Bonus - Previous Brokers Telephone No
11. Do you wish to protect your no claim discount by payment of an additional premium?	Yes No
(Only available if you are over 21 years and entitled to 4 years No Claim Bonus).
1 2) a. Please indicate by a tick in each appropriate box the use of the proposed vehicle.
Social, Domestic and Pleasure To travel to work by the proposer Other Use (give details)
To travel to work by another driver (indicate which driver)
the proposer for the business of the proposer
b. Will the vehicle be used in connection with motor sport or for motor trade purposes ?	Yes No
If yes, Give full details
13. Indicate the cover you required Comprehensive Third Party Fire & Theft Third Party Only
14. If restricted mileage please state precise recorded mileage of the vehicie at the date of the proposal
15. If restricted mileage please state maximum annual mileage of the vehicle
(Limited mileage contracts are available for 1500 miles, 3000 miles, 4500 miLes, 6000 miles, 7500 mites ond unlimited),

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