Mini Bus Make:    Model:

Engine size cc  Petrol or Diesel Diesel Petrol Other

If other please specify

Approximate date you purchased vehicle:

Number of Passenger Seats (excluding front seats)

Are seats front facing Yes No Seat Belts on all seats Yes No

Year:   Value:  Renewal Date:

No of Doors:            Is the Vehicle Modified:   NO Yes

Modified: If Yes please list modifications below

Cover:        Comprehensive Third Party Fire & Theft Third Party Only  

 Drivers:      Insured Only Insured & Spouse Insured & One named Driver Insured & Two named Drivers Insured & Three named Drivers Any Approved Driver  

NCD:         65% Four years plus 50% Three years 40% Two years 30% One year NIL     Protected: YES No

Garaged:     Yes No    Excess: £400 £300 £250 £200 £150 £100 £50 Nil

Vehicle Usage:   Social Domestic & Pleasure Social Domestic & Pleasure & Commuting SD&P & Personal Business Use SD&P & Full Business Use Commercial Travelling Courier Hire or Reward Taxi

                        Annual Mileage:   4000 per annum 5000 per annum 8000 per annum 10000 per annum 12000 per annum 12000 plus per annun

Home Owner:   YES NO            Post Code:  

Email:  

Address:

Age or Date of Birth:       Male/Female: MALE FEMALE

Licence:                       Full Provisional International    Years:

Use of other cars:         Yes No    Marital Status: Married Common Law Single

Exact Occupation:      

Part Time Occupation

Disabilities:                  None Heart Conditions Epilepsy Diabetes Defective Vision Defective hearing Mental Infirmity Fits of any Kind

Has your disability been notified to the DVLA     Yes No N/A

Smoker:                       YES NO

DETAILS OF ACCIDENTS    One None Two Three Four  during the last 5 years

Complete accident details below:

Give Dates: Amounts Claimed, Fault, Third Party Payouts,

NUMBER OF MOTORING CONVICTIONS

  None One Two Three Four received during the last 5 years

_{Details:  Name    Code    Fine    Dates    Penalty Points    Licence Suspension}

NAMED DRIVERS:   None One Two Three   

Details of each additional named driver required as follows:

Name - Occupation - Age- Type of business or work involved - Does he/she own their own car - Licence type -  & how many years held - relationship to insured - Use of car for what purpose - Does the additional driver have any NCD in own name. Any claims or convictions or disabilities

Signed:

Title:  First name:     Last:  

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