Insurance Quote Form

INSURANCE QUOTE FORM:
POLE POSITION RACING
MOTORCYCLE SHOP / RACING TEAM

Unit 5, 100 The Highway London E1W 2BX,
Tel: 0044(0)20 7702 9381, Fax: 0044(0)20 7998 0586

Company Registration Number: 6683127
1. Full Name

First NameLast Name
2. E-mail
3. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
4. Phone Number

Area CodePhone Number
5. Birth Date

DayMonthYear
6. Profession
7. Are you a resident in the UK?
8. If not born in the UK when did you arrive to the UK
9. Are you a home owner, otherwise, please state whether you share or live with parents
10. What is your marital status
11. Medical conditions if any
12. Have you ever cancelled insurance before? If yes, state why
13. What type of driving licence: full / provsional (British/EU, EEC/ other etc)
full/ provisional, please state
14. CBT/UK Provisional-When has been done?
15. How long have you had this driving license for
16. Do you have a car you would like to insure
17.Have you had any other quote and how much for
18. When does your current insurance expires/ or expired?

MonthDayYear
19. What type of insurance do you require ?
20. What is your attempted use?
21. Have you had an accident during last five years,
22. If yes; provide the details where, when and short info how did it happen.
23. Did you get your compensation and how much did you receive
24. Have you had any motoring convictions during the last five years (for example: speeding, drink driving)
25. If yes, provide details
26. Have you received bans/ disqualifications from driving during last 11 years
27. How many years NO CLAIM BONUS
Details of a motorcycle to be insured: All fields are compulsory
28. Make
29. Model
30. Registration Number
31. Capacity of the engine in CC /CM3
32. Year of production
33. Estimated mileage per year
31. Are you the only registered keeper
32. Is there an ABS fitted in the vehicle?
33. What type of security is currently n the vehicle (alarm, tracker, chain etc)
34. Detailed description of your security system (example: Datatool S4 C1 Red, Tracker Monitor, Thatcham Category 3 security chain)
35. Where is the motorcycle kept (a garage, off street parking etc)
35a. If off-street parked - what are the conditions?
36. If a vehicle kept in a garage –what is the garage made of (brick, wood etc)
37. Is the motorcycle with a trailer?
38. Turbo?
39. Panniers?
40. What is the estimated market value of the vehicle?
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Request to Pole Position Racing Ltd: Please provide me with an insurance quote using my details listed above. Information given to you is to my best knowledge true.

All information is confidential
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INSURANCE QUOTE FORM:

Request to Pole Position Racing Ltd: Please provide me with an insurance quote using my details listed above. Information given to you is to my best knowledge true.