Private Car

Risk Questionnaire

Client Details and General Information

Full Client Name
Address

Title
First name
Surname
Date of birth
Correspondence address
Gender
Marital status
Homeowner
Number of vehicles in
household
Cover basis
Voluntary excess requested
()

0.00

Period of Insurance
Effective Date

23 April 2007

Term End Date

22 April 2008

Scope of Cover
Sections covered by this Questionnaire
The following risks are covered in this questionnaire:
Vehicle

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ

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Pri vate Car Ris k Questi onnaire XZXZXZ

Vehicle
Registration number
Vehicle
Overnight parking postcode
Overnight parking
Valid drivers
Year first registered (yyyy)
Value
Vehicle body type
Number of seats
Vehicle annual private mileage
Vehicle annual business mileage
Security device
Security device type
Vehicle accessories value
Security device fitter
Left or right hand drive
Modified
Type of modification
Modification due to medical condition
Vehicle registered keeper
Vehicle owner
Previously insured
Previous insurer
Previous policy number
Previous policy expiry date (if N/A, enter current date)
NCB years
Protected NCB requested
NCB type (If N/A, use Private Car Bonus)

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ

Null

Pri vate Car Ris k Questi onnaire XZXZXZ

Vehicle
Registration number
Vehicle
Overnight parking postcode
Overnight parking
Valid drivers
Year first registered (yyyy)
Value
Vehicle body type
Number of seats
Vehicle annual private mileage
Vehicle annual business mileage
Security device
Security device type
Vehicle accessories value
Security device fitter
Left or right hand drive
Modified
Type of modification
Modification due to medical condition
Vehicle registered keeper
Vehicle owner
Previously insured
Previous insurer
Previous policy number
Previous policy expiry date (if N/A, enter current date)
NCB years
Protected NCB requested
NCB type (If N/A, use Private Car Bonus)

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ

Other Driver
Relationship to proposer
Frequency of use
Class of use
Driver title
Driver first name
Driver surname
Driver date of birth
Years resident in UK
Driver gender
Driver marital status
Driver licence type
Driver licence valid from
Additional driving qualifications
Number of other vehicles driven
Driver owns other vehicles
Driver occupation
Driver type of business
Driver employment status
Full time employment
Driver additional occupation
Driver additional occupation employment status
Does the driver have any medical conditions that may affect his
ability to drive
Is the driver a smoker
Cover previously refused
Special restrictions previously imposed
Previous convictions
Prosecution pending
Any claims with a previous insurer

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ

Other Driver
Relationship to proposer
Frequency of use
Class of use
Driver title
Driver first name
Driver surname
Driver date of birth
Years resident in UK
Driver gender
Driver marital status
Driver licence type
Driver licence valid from
Additional driving qualifications
Number of other vehicles driven
Driver owns other vehicles
Driver occupation
Driver type of business
Driver employment status
Full time employment
Driver additional occupation
Driver additional occupation employment status
Does the driver have any medical conditions that may affect his
ability to drive
Is the driver a smoker
Cover previously refused
Special restrictions previously imposed
Previous convictions
Prosecution pending
Any claims with a previous insurer

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ

Other Driver
Relationship to proposer
Frequency of use
Class of use
Driver title
Driver first name
Driver surname
Driver date of birth
Years resident in UK
Driver gender
Driver marital status
Driver licence type
Driver licence valid from
Additional driving qualifications
Number of other vehicles driven
Driver owns other vehicles
Driver occupation
Driver type of business
Driver employment status
Full time employment
Driver additional occupation
Driver additional occupation employment status
Does the driver have any medical conditions that may affect his
ability to drive
Is the driver a smoker
Cover previously refused
Special restrictions previously imposed
Previous convictions
Prosecution pending
Any claims with a previous insurer

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ

Claims History

02/10/2013

Private Car Risk Questionnaire for

XZXZXZ