Corporate Clients

Please complete all of the following fields.
**Denotes compulsory field

Name Of Insured

Contact Name **

Contact Number **

Email **

Preferred contact method

Please select Phone Email

Business Description

Year Business Established

Are you a new or existing client?

Please select New Existing

If new, please advise how you got our name

Please select Websearch Recommendation Advertising Other

If existing, please enter your Client Reference if known

Do you currently have fleet insurance for this business?

Please select Yes No

If yes, what is the renewal date?

D: M: Y:

What is the current annual premium that you pay?

Type of business

Number of years (approx) that you have held a fleet policy

Number of vehicles to be insured?

Are all vehicles registered to the company?

Please select Yes No

Vehicle Use

Please select Social, Domestic & Pleasure Pre-arranged business appointments Other

Who is to be insured to drive these vehicles?

Please select Any Any Driver aged 21 and over Any Driver aged 25 and over Any Driver aged 30 and over

What type of cover do you require on the vehicles?

Please select Comprehensive Third Party Fire and Theft Third Party Only

Please state the number of claims in the past 3 years (approx)

Please state the total no. of convictions that your drivers currently have in the last 3 years **

Do any drivers have any serious convictions (drink drive etc.)

Please select Yes No

Please provide any further details relating to your application (e.g. ever had request for insurance declined? / any driver medical conditions / any criminal convictions?)