Our Privacy Statement, Terms and Conditions and other important documents are those on which we intend to rely and for your own benefit and protection we urge you to read these carefully before proceeding. If you do not understand any point please ask for further information.

I agree to receiving marketing information from Bridge Insurance Brokers Ltd or from selected business partners Yes No

CONTACT INFORMATION

Your name:

Your telephone number:

Your email:

Best time to call you:

1st line of your address:

Postcode:

VEHICLE INFORMATION

Make of Vehicle:

Model:

Registration (if known):

Year of registration:

Engine Size (CC):

Gross Vehicle Weight (if known):

Gears:

Manual Automatic

Fuel Type:

Petrol Diesel Bio-Fuel Hybrid Other

Where is the vehicle kept overnight:

Please select Garaged On Drive Locked Compound On Private Road On Public Road Other

1st Line of address where the vehicle is kept:

Postcode of where vehicle is kept:

POLICY INFORMATION

Registered owner / Keeper of the Vehicle (if different from above):

Driving Restriction:

Please Select Any Driver Over 30 Insured Only Other

Average Mileage Per Year (business):

Up to 5,000 5,000 - 7,500 7,500 - 10,000 10,000 - 12,500 12,500 - 15,000 15,000 - 17,500 Over 17,500

Average Mileage Per Year (personal):

None Up to 2,500 2,500 - 5,000 5,000 - 7,500 7,500 - 10,000 Over 10,000

Cover required:

Comprehensive Third Party, Fire and Theft

No claims bonus available to use on vehicle:

0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years Over 7 years

Do you wish to protect your no claims bonus:

No - Not Protected Yes - Protected

POLICYHOLDER / MAIN DRIVER

Policyholder Name:

Salutation:

Please select Mrs Miss Mr Ms N/A - Company Name Other

Main user name (if different to above)

Salutation:

Please select Mrs Miss Mr Ms N/A - Company Name Other

Date of birth

(dd/mm/yyyy)

Marital Status:

Please select Married Single Living with Partner Other

Licence Type:

Please Select Full UK Provisional European International Other

Number of years held:

Please Select 0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 5 - 10 Years Over 10 Years Other

Do you have use of another vehicle:

Please Select Yes - My own vehicle Yes - Another vehicle No

Is there no claims bonus available:

None 1 year 2 Years 3 Years 4 Years 5 Years 6 Years Over 6 Years

Voluntary Excess:

Please Select None £100 £150 £200 £250 £300 £350 £500 £1000

MOTORING CONVICTIONS

Have any of the drivers had any motoring convictions, disqualifications or prosecutions pending:

Please Select Yes - Please State Below No

Driver name:

Date of conviction: Conviction Code: Please Select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CU10 CU20 CU30 CU40 CU50 DD40 DD60 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 TT99 UT50 OTHER

Fine amount:

£

Points: Please Select 0 Points 3 Points 4 Points 5 Points 6 Points 7 Points 8 Points 9 Points 10 Points 11 Points 12 Points Banned - State period Length of Ban (if app.) None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Over 24 months

Driver name:

Date of conviction: Conviction Code: Please Select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CU10 CU20 CU30 CU40 CU50 DD40 DD60 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 TT99 UT50 OTHER

Fine amount:

£

Points: Please Select 0 Points 3 Points 4 Points 5 Points 6 Points 7 Points 8 Points 9 Points 10 Points 11 Points 12 Points Banned - State period Length of Ban (if app.) None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Over 24 months

Driver name:

Date of conviction: Conviction Code: Please Select AC10 AC20 AC30 BA10 BA30 CD10 CD20 CD30 CD40 CD50 CD60 CD70 CU10 CU20 CU30 CU40 CU50 DD40 DD60 DD80 DR10 DR20 DR30 DR40 DR50 DR60 DR70 DR80 DR90 IN10 LC20 LC30 LC40 LC50 MS10 MS20 MS30 MS40 MS50 MS60 MS70 MS80 MS90 MW10 PC10 PC20 PC30 SP10 SP20 SP30 SP40 SP50 SP60 TS10 TS20 TS30 TS40 TS50 TS60 TS70 TT99 UT50 OTHER

Fine amount:

£

Points: Please Select 0 Points 3 Points 4 Points 5 Points 6 Points 7 Points 8 Points 9 Points 10 Points 11 Points 12 Points Banned - State period Length of Ban (if app.) None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Over 24 months

CLAIMS HISTORY

Have you or any drivers had any accidents, losses or incidents in the last 5 years:

Please Select Yes - Please State Below No

Driver name:

Description:

 

Date:         Amount/cost: £

Driver name:

Description:

 

Date:         Amount/cost: £

Driver name:

Description:

 

Date:         Amount/cost: £

YOUR CURRENT INSURANCE

Who is your current insurer?

When is cover required?

(dd/mm/yyyy)

What are you currently paying?

£

Any further information:

NOTE: If information provided is incorrect or incomplete Insurers may not pay your claim. Details you provide may be checked by Insurers against data held elsewhere.

Please contact us on 0845 313 9871 if you cannot proceed any further.