To receive a quotation for Kit/Specialist Car Insurance please complete this form.

Proposer: Address: Postcode:     E-mail Address:  Home Telephone:      Work:      Mobile:  Car:     Model:   Engine Make/Model:        CC:      Petrol /Diesel Engine BHP If Known:  Please provide details of best quote obtained elsewhere:  £ Quote obtained from:

On The Road Cover

Minimum policy term twelve months.

Maximum four drivers, age 18 - 74, minimum 1 year full licence.

Maximum value £5,000 for third party, fire and theft cover.

Garaging required in some postcodes irrespective of value and in all postcodes for values of £15,000 or more.

Cover Required: Comprehensive /Third Party Fire & Theft / Third Party Only Limited Mileage: 1500 /3000 / 5000 / 7500 /10000 / Unlimited Car Value:  £         Lefthand Drive:  Yes /No        Garaged:  Yes /No Age of vehicle in current form (not donor vehicle age):  years Is the car fitted with a Thatcham Cat 1 Alarm and Immobiliser or tracker:  Yes /No NB An immobiliser only cannot be CAT 1 but may be CAT 2 Are you a member of a Kit Car Club:  Yes /No     IF YES which one:  Will this be your only or main vehicle:  Yes /No Drivers:  Self Only / Self & Spouse /Self & 1 Named / More Than 2 (max 4)

Proposer / Driver 1 Name:    Date of Birth:  Occupation:     Nature of Business:     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 Name:    Date of Birth:  Occupation:     Nature of Business:     Relationship To Driver 1:     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 Name:    Date of Birth:  Occupation:     Nature of Business:     Relationship To Driver 1:     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 Name:    Date of Birth:  Occupation:     Nature of Business:     Relationship To Driver 1:     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"

Have you or ANY driver now proposed:-  A, been involved in any accident or loss regardless of blame in the last 3 years, whether or not a claim was made:  Yes /No B, been convicted of a motoring/fixed penalty offence in the last 5 years or have any prosecution pending/police enquiries outstanding (including fixed penalty offences):  Yes /No C, ever been disqualified from driving, refused insurance or quoted increased premium or had special terms imposed:  Yes /No D, had any motor vehicle stolen or suffered any loss by theft/vandalism of or from a motor vehicle in the last 3 years whether or not a claim was made:  Yes /No E, ever suffered/currently suffer from any physical/mental infirmity, heart/diabetic/epileptic or other medical condition, defective vision/hearing not corrected by optical/hearing aids, or regularly take any prescribed drugs:  Yes /No F, ever been convicted of or cautioned for any criminal offence of any kind or have any prosecution pending:  Yes /No

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.