Eazy Insure

Car Insurance Quotation Form

Online

Phone

How did you hear about us?

If by a friend, family or referrer please state their name

Have you or any of the drivers ever had insurance declined, cancelled or special terms imposed? *

“Registered with the ICO, all your personal information is protected under the Data Protection Act 1998”

Personal Info

Title *

First Name *

Surname (Including any middle names) *

Date of Birth *

House Number/Name *

First Line of Address *

Postcode *

Marital Status *

Employment Status *

If Employed/Self Employed, What is your occupation:

If Employed/Self Employed, What is your Business:

Home Owner *

Any Children under 16*

Contact Info

Email address *

Mobile *

Phone

Please contact me via

Phone

Text

Driving History

Type of License *

Period Licence held for *

If held for 3 years or less, what date was licence obtained

Please enter your 16-character GB driving licence number

This may reduce your price

DVLA medical conditions or disabilities *

Any additional driving qualifications *

If one is selected, what date was qualification obtained

Were you born in the UK *

If No, when did you last become a UK resident

Use of any other vehicles *

Non motoring criminal convictions

Any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years *

Motor Accidents or Claim Details

1

Type :

Date :

Damage :

Cost(£) - if known :

Fault :

Any Injuries :

Yes

2

Type :

Date :

Damage :

Cost(£) - if known :

Fault :

Any Injuries :

Yes

3

Type :

Date :

Damage :

Cost(£) - if known :

Fault :

Any Injuries :

Yes

4

Type :

Date :

Damage :

Cost(£) - if known :

Fault :

Any Injuries :

Yes

In the last 5 years, has the driver had any motoring offences, including fixed penalties, convictions, driver awareness courses or disqualifications, or any pending prosecutions? *

Motor Conviction, Fixed Penalty or Disqualification Details

1

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

2

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

3

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

4

Conviction Code:

Date of Conviction:

Points:

Fine(£) - if any:

Ban(months) - if any:

Vehicle Details

Vehicle Registration *

Tick this box if you don't know the vehicle registration

Car Details

Manufacturer:

Model:

Registration Year:

Alarms - Immobiliser: *

Number of Seats: *

Number of Doors: *

Engine Size (CC):

Transmission:

Manual

Automatic

Actual value of car at the present (£) *

Does the vehicle have any modifications? *

Yes

Date of purchase: *

No Recommendation

Registered Keeper: *

Legal Owner: *

Is the car impounded with the police?

Vehicle Usage

Where is the vehicle kept during the day: *

Where is the vehicle kept overnight: *

Is the vehicle kept at the same address: *

If No, what is the full address of where the vehicle is kept:

Use of vehicle: *

Estimated Annual Mileage: *

Type of Cover: *

Do You Have NCD? *

Yes

Any no claims discount: *

How did you earn your no claims discount:*

Was this NCD earned in the UK: *

Would you like to protect your NCD: *

What voluntary excess would you like: *

How do you normally pay for insurance: *

Please provide your Current/Previous Insurer’s name:

This may reduce your price

When would you like the policy to start: *

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Car Insurance Quotation Form

Personal Info

Contact Info

Driving History

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4

Vehicle Details

Car Details

Vehicle Usage

Additional Driver

Additional Driver (1) Details

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4

Additional Driver (2) Details

Motor Accidents or Claim Details

1

2

3

4

Motor Conviction, Fixed Penalty or Disqualification Details

1

2

3

4