Spa Insurance Services

Please complete all the details required below

Personal Details
Name
House Number/Name
Postcode
Daytime Telephone Number
Evening Telephone Number
e-mail Address

Vehicle Details
Manufacturer
Model
Year and Reg Letter
Engine Size (cc)
Fuel Type
Value
Number of seats
Any Modifications	Yes No
Please give details of any Modifications

Cover Details
Cover Type
Drivers
Usage
How many years no claims?
Do you require protected no claims?	Yes No
Company Car Experience - Years claim free
Do you require a voluntary excess?
Company Car Experience - Finished
Did/Does this include private use?	Yes No
Where is the vehicle kept overnight?
Private Mileage
Business Mileage
Who is the owner/registered keeper of the vehicle?

Driver Details - Main Driver
Name
Sex	Male Female
Date of Birth
Marital Status
Type of Licence Held
Licence Date
Do you have access to any other vehicle in the household?	Yes No
How long have you resided in the UK?
Have you completed or considered taking the passplus course?	Yes No
Are you a home owner?	Yes No
Have you ever been refused insurance?	Yes No
Occupation
Have you been involved in any accidents or suffered any claims/losses in the past five years?	Yes No
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?	Yes No
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?	Yes No
Give brief details of the condition(s) that may affect your driving
Policy Renewal Date
What is your best quote to date?
Which insurance company quoted this?
Preferred Contact Method
Enquiry Source
(if other source please state)
Please use the space below to give us any further information.

If you require more than one driver to be insured, please provide the additional driver details below before submitting this form
Driver Details - Spouse/First Driver
Name
Sex	Male Female
Date of Birth
Marital Status
Type of Licence Held
Licence Date
Do you have access to any other vehicle in the household?	Yes No
How long have you resided in the UK?
Have you completed or considered taking the passplus course?	Yes No
Are you a home owner?	Yes No
Have you ever been refused insurance?	Yes No
Occupation
Have you been involved in any accidents or suffered any claims/losses in the past five years?	Yes No
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?	Yes No
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?	Yes No
Give brief details of the condition(s) that may affect your driving

Driver Details - Second Driver
Name
Sex	Male Female
Date of Birth
Marital Status
Type of Licence Held
Licence Date
Do you have access to any other vehicle in the household?	Yes No
How long have you resided in the UK?
Have you completed or considered taking the passplus course?	Yes No
Are you a home owner?	Yes No
Have you ever been refused insurance?	Yes No
Occupation
Have you been involved in any accidents or suffered any claims/losses in the past five years?	Yes No
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?	Yes No
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?	Yes No
Give brief details of the condition(s) that may affect your driving

Driver Details - Third Driver
Name
Sex	Male Female
Date of Birth
Marital Status
Type of Licence Held
Licence Date
Do you have access to any other vehicle in the household?	Yes No
How long have you resided in the UK?
Have you completed or considered taking the passplus course?	Yes No
Are you a home owner?	Yes No
Have you ever been refused insurance?	Yes No
Occupation
Have you been involved in any accidents or suffered any claims/losses in the past five years?	Yes No
Please give details of any claims, specifying the date, a brief description of what happened, if you were to blame, if your no claims bonus was affected and an approximate amount of the claim.
Any Driving convictions / endorsements?	Yes No
Enter details of convictions/endorsements. Give dates, Licence endorsement code and number of points. Please State if you were disqualified.
Any medical conditions or disabilities?	Yes No
Give brief details of the condition(s) that may affect your driving

Spa Insurance Services Ltd is Authorised and regulated by the Financial Services Authority
FSA Reference number is 450429