To receive a quotation for Classic Car Insurance please complete this form.

Proposer / Driver 1:  Address: Postcode:       E-mail Address:  Home Telephone:      Work Tel:      Mobile:  Car Make:      Car Model:         Car Age:   Car Value:  £   Mileage:  0 /1500/3000 /5000   Engine Size:  cc Wedding Use:  Yes /No        If yes which cover:  Annual /Per Wedding Age of youngest driver:  (minimum age 25) Is this your only or main vehicle:  Yes /No  Will it be garaged:  Yes /No     Has it been modified:  Yes /No Details of modifications:  Are you a member of a Classic Car Club:  Yes /No If YES which club:

Proposer / Driver 1 Drivers Name:   Age:  (min 25) Occupation:     Please state the number of years claim-free insurance record:  years NB: Number of years claim free not "maximum" and not percentage.  NOT number of years NCD Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occuring during the last five years and any criminal convictions / driving disqualifications: If you do not have anything to enter in the above box please enter "none"

Driver 2

Drivers Name:   Age:  (min 25) Occupation:     Please state the number of years claim-free insurance record:  years NB: Number of years claim free not "maximum" and not percentage.  NOT number of years NCD Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occuring during the last five years and any criminal convictions / driving disqualifications: If you do not have anything to enter in the above box please enter "none"

Driver 3

Drivers Name:   Age:  (min 25) Occupation:     Please state the number of years claim-free insurance record:  years NB: Number of years claim free not "maximum" and not percentage.  NOT number of years NCD Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occuring during the last five years and any criminal convictions / driving disqualifications: If you do not have anything to enter in the above box please enter "none"

Driver 4

Drivers Name:   Age:  (min 25) Occupation:     Please state the number of years claim-free insurance record:  years NB: Number of years claim free not "maximum" and not percentage.  NOT number of years NCD Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occuring during the last five years and any criminal convictions / driving disqualifications: If you do not have anything to enter in the above box please enter "none"

Driver 5

Drivers Name:   Age:  (min 25) Occupation:     Please state the number of years claim-free insurance record:  years NB: Number of years claim free not "maximum" and not percentage.  NOT number of years NCD Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occuring during the last five years and any criminal convictions / driving disqualifications: If you do not have anything to enter in the above box please enter "none"

Driver 6

Drivers Name:   Age:  (min 25) Occupation:     Please state the number of years claim-free insurance record:  years NB: Number of years claim free not "maximum" and not percentage.  NOT number of years NCD Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occuring during the last five years and any criminal convictions / driving disqualifications: If you do not have anything to enter in the above box please enter "none"

All quotes are subject to satisfactory proposal form, evidence of no-claims record, copy licences etc.  The insurers reserve the right to decline any proposal submitted.

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