Motorhome Insurance Quote Request Form

If you’ve been given a code by your Motorhome Dealer please enter it here:

Name *

Title First Name Last Name

Address *

Street Address Line 1

Street Address Line 2

City County

Postcode

Date of birth *

Day Month Year

Email Address *

Mobile Number *

Vehicle owners club

Have you had any previous Motorhome insurance policies *

Yes No

Date policy to start *

Date

Cover *

VIN *

Make *

Model *

Fuel Type *

Number of belted seats *

Number of doors *

Right or left hand drive *

Right hand drive Left hand drive

Is the motor home being used by any person for "full timing" *

Yes No

Registration number *

Estimated value in £ *

Engine Size *

Transmission *

Automatic Manual

Year of make *

Vehicle body type *

Use required *

Expected annual mileage *

Is the vehicle being kept at the propser address *

Yes No

Postcode where kept overnight *

Street Address

Street Address Line 2

Postcode

Where is the vehicle is kept overnight? *

Please give details here: *

Registered keeper *

Please give details here: *

Vehicle owner *

Please give details here: *

Have you purchased the vehicle *

Yes No

Date of purchase *

How many years no claims discount you have on a motorhome insurance policy *

Do you require protected no claims bonus *

Yes No

Are there any changes from the manufacturer's standard specification *

Yes No

Please give details here: *

Are any security devices, other than the manufacturer standard equipment, fitted? *

Yes No

Please give details here: *

Who will be driving the vehicle *

Main Driver *

UK resident since birth *

Yes No

Marital status *

UK resident since *

Day Month Year

Do you have access to an everyday motor vehicle? *

Yes No

How many vehicles do you own or have access to other than the one to be insured *

Type of driving licence *

Date obtained *

Day Month Year

Driving licence number *

Employment status *

What is your occupation *

Nature of your Business *

Please list ALL drivers below *

	Spouse/ Partner	Declared Driver #1	Declared Driver #2	Declared Driver #3
Relationship to proposer
Permanent UK resident
Title
First Name
Last Name
Date of Birth
Gender
Marital Status
No. of Vehicles owned
Number of other vehicles driven
Type of License
Date Passed
License Number
Primary Employement Type
Full Time/ Part Time
Occupation
Business
*Secondary Employment Type If not applicable note N/A
*Full Time/ Part Time If not applicable note N/A
*Occupation If not applicable note N/A
*Business If not applicable note N/A

Does any driver have any CCJs *

Yes No

Please give details here: *

Have you or any person who drives suffered a disability or medical condition that must be revealed to the DVLA? *

Yes No

Please give details here: *

Have you or any person who may drive had an insurance policy refused/declined, cancelled/voided or any special terms imposed? *

Yes No

Please give details here: *

In the last five years, have you or any person who may drive been convicted of any motoring offence (including fixed penalties), been disqualified from driving or are there any prosecutions pending? *

Yes No

Please list all driver motoring convictions below *

	Proposer	Spouse/ Partner	Declared Driver #1	Declared Driver #2	Declared Driver #3
Offence Code
Offence Date
Conviction Date
Penalty Points
Fine Received in £
Disqualification Period in Months

Has anyone who may drive been convicted or have pending convictions for any non-motoring offence? *

Yes No

Please list all driver non motoring convictions below *

	Proposer	Spouse/ Partner	Declared Driver #1	Declared Driver #2	Declared Driver #3
Offence Date
Offence Type
Sentence Type
Length of Sentence in Months
Early Release Date

Have you or any person who may drive had any accidents/claims/losses (whether to blame or not) in connection with any motor vehicle during the last three years? *

Yes No

Please list all driver accidents/claims/losses below *

	Proposer	Spouse/ Partner	Declared Driver #1	Declared Driver #2	Declared Driver #3
Date of Accident
Brief Details of Accident
Who was at fault?
Total Repair Cost in £
Was there a personal injury claim? (YES or NO)
Has the claim been settled? (YES or NO)

Registration number

Name of previous insurer

Policy number

Expiry date

No Ccaims bonus entitlement in years

Additional supporting information

Confirmation *

I confirm that as the proposer I have read this form and completed the information in order to provide me with an insurance quotation

Please verify that you are human *

Motorhome Insurance Quote Request Form

1) Policy Holder Information:

2) About your vehicle:

3) Vehicle Security & Modifications:

4) Drivers:

5) Motoring convictions:

6) Non motoring convictions:

7) Accidents / Claims / Losses:

Insurance history:

8) Additional supporting information: