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

Your Name:  Address: Postcode:     E-mail Address:  Home Telephone:      Work:      Mobile:  Car:  MCC Smart      Model:        BHP:  Car type:  Cabrio /Coupe Engine Size:  CC          Petrol /Diesel Please provide details of best quote obtained elsewhere:  £ Quote obtained from:

Modifications

Is the car 100% factory standard and unmodified:  Yes /No If NO please provide details of all modifications including Body/Engine/Wheels/Interior: Is the bodywork / paintwork standard:  Yes /No If NO please provide details of all modifications:

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:  years     Year vehicle registered:  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 Smart Car Club:  Yes /No  IF YES which one:  Will this be your only or main vehicle:  Yes /No Are you the owner:  Yes /No If NO then who is:  Are you the registered keeper:  Yes /No Are you the main user:  Yes /No Drivers:  Self Only / Self & Spouse /Self & 1 Named / More Than 2 (max 4) Class of use:  Class 0 / Class 4 / Class 1 /Class 2 / Class 3 Class 0, Social Domestic & Pleasure (excluding commuting) of use:  covers you and other permitted drivers to use the car for social, domestic & pleasure purposes only. Class 4, Social Domestic & Pleasure (including commuting) of use:  covers you and other permitted drivers to use the car for social, domestic & pleasure purposes including travel to / from a single permanent place of work (a minimum of class 1 is necessary if you have several places of work). Class 1:  incorporates class 4 as well as use by you, or your spouse (if entitled to drive), in connection with either of your occupations.  This will not cover use in connection with the Motor Trade, use for the soliciting of orders, hire of the car, or carriage of goods or passengers for hire or reward. Class 2:  covers classes 0 & 4 and use by you and authorised drivers in connection with your occupation.  Excludes use in connection with the motor trade, use for the soliciting of orders, renting out or use for carriage of goods or passengers for hire or reward. Class 3:  covers class 2 above and also includes the soliciting of orders. Class 2 & 3 cover available in selected cases only - subject to individual approval.

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. Is this NCD available for transfer to the proposed new policy:  Yes /No Please give full details of any medical conditions and any accidents / losses / claims / motoring convictions occurring 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 occurring 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 occurring 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 occurring 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.