Motorhome Insurance Quote Request Form
If you’ve been given a code by your Motorhome Dealer please enter it here:
1) Policy Holder Information:
Name
*
Mr.
Mrs.
Miss.
Ms.
Dr.
Title
First Name
Last Name
Address
*
Street Address Line 1
Street Address Line 2
City
County
Postcode
Date of birth
*
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Month
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1926
1925
1924
1923
1922
1921
1920
Year
Email Address
*
Mobile Number
*
Vehicle owners club
Have you had any previous Motorhome insurance policies
*
Yes
No
2) About your vehicle:
Date policy to start
*
/
Day
/
Month
Year
Date
Cover
*
Comprehensive
Third Party, Fire and Theft
Third Party Only
VIN
*
Make
*
Model
*
Fuel Type
*
Petrol
Diesel
Electric – Petrol
Electric – Diesel
Electric only
Compressed Natural Gas
Hydrogen
LPG
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
*
Coachbuilt/ Motor Caravan
Campervan
A-Class
American Motorhome
Use required
*
Social, Domestic and Pleasure (SDP)
Social, Domestic, Pleasure and Commuting (SDP+C)
Personal Business use (SDPC+business use)
Expected annual mileage
*
Is the vehicle being kept at the propser address
*
Yes
No
Postcode where kept overnight
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Where is the vehicle is kept overnight?
*
At home in a locked garage
At home on a driveway
At home on the road
In a caravan park
On a storage compound
Other
Please give details here:
*
Registered keeper
*
Proposer
Spouse
Lease Company
Other
Please give details here:
*
Vehicle owner
*
Proposer
Spouse
Lease Company
Other
Please give details here:
*
Have you purchased the vehicle
*
Yes
No
Date of purchase
*
/
Day
/
Month
Year
How many years no claims discount you have on a motorhome insurance policy
*
0
1
2
3
4
5
6
7
8
9+
Do you require protected no claims bonus
*
Yes
No
3) Vehicle Security & Modifications:
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:
*
4) Drivers:
You must provide the details of yourself and any other person who may drive.
Who will be driving the vehicle
*
Insured only
Insured and Partner/Spouse
Any Named Driver
Main Driver
*
Proposer
Spouse
Declared Driver 1
Declared Driver 2
Declared Driver 3
UK resident since birth
*
Yes
No
Marital status
*
Single
Married
Common Law Partner
Divorced
Widowed
Civil Partnered
UK resident since
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
*
1
2
3
4
5
6
7
8
9
10
Type of driving licence
*
Full UK
Provisional UK
International
Automatic Only
EU Full
Date obtained
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Driving licence number
*
Employment status
*
Employed (Full Time)
Employed (Part Time)
Self Employed
Retired
Unemployed
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:
*
You are reminded that you are required by law to inform Drivers Medical Enquiries, DVLA, Swansea SA99 1TU, at once, if you have any disability (including any physical or mental condition) which is or may become likely to affect your fitness as a driver.
5) Motoring convictions:
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
6) Non motoring convictions:
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
7) Accidents / Claims / Losses:
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)
Insurance history:
Registration number
Name of previous insurer
Policy number
Expiry date
-
Day
-
Month
Year
No Ccaims bonus entitlement in years
8) Additional supporting information:
Use the next space to provide any other information that you deem appropriate
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
*
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