Fleet Quotation Form (fields with * are mandatory) Company Name* Contact Name* Email Address Postal Code Phone* Occupation   Has the Insured of Any Driver had any Accidents (within last 5 yrs)/Claims ( within last 5 yrs)/Convictions(ever) or suffer from any Disabilities/Medical Conditions Yes No If yes, please give details If applicable, please supply confirmed Claims Experience from previous insurers in respect of the last 5 years, If not, please advise No Claim Bonus in years relating to each vehicle, Please note we cannot proceed with quote unless we are in receipt of this information. Vehicles (Records with empty Reg No will not be saved.) Reg No Make & Model CarCap GVW/cc's Tow Bar Type of Body No of Seats Year Value Cover Bonus (if applicable) Are you the registered owner of the above vehicles? Yes No If No, Please give full details Have any of the above vehicles been modified, specially built or fitted with special equipment? Yes No If Yes, Please give full details Use Carriage of Own Goods Only Yes No Hire or Reward Yes No If yes, do you require Continental use? Yes No If used for carriage of goods, will any goods be of an Explosive, Corrosive, Radioactive, or other Hazardous nature? Nature of Goods Carried Drivers (Records with empty Driver Name will not be saved.) We wish to confirm all our Fleet Policies allow Open Driving 26 - 65 with full driving licence. Name Occupation Date of Birth Licence Held(F/P) Licence Held (Yrs) Yes  No Yes  No Yes  No Yes  No Yes  No Additional Comments