Broad Insure | Car Quote Form

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0330 113 0505

Van 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 *

Middle Name (If any)

Last Name *

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 :

Vehicle Registration *

Approximate value of the van right now *

Manufacturer

Model

Registration Year

Alarms - Immobiliser

Number of Seats

Number of Doors

Engine Size (CC)

Transmission

Manual

Automatic

Fuel type

Body type*

Roof Type*

Wheel Base*

Does the vehicle have any modifications? *

Yes

Please advise on what modifications have been made to the van

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:

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

Yes

What do you use the Van for? *

Estimated Annual Mileage *

Type of Cover *

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 *

Additional Driver

Would you like to add another additional driver

Yes

Additional Comments

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By clicking submit, you agree your explicit consent for us to use the data provided in accordance with the Data Protection
act 1998, this data will be used to provide the cheapest possible quote while being shared with both offline and online markets.

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Van 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

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