lm2hz – Ability Drive

Client Details and General Information

Answer the questions you can but do not worry if you do not have all the answers. Just submit what you can and we can come back to you to work together to complete them.

Name*

Email*

Phone*

Address*

Period of Insurance

Effective Date

Vehicle

Cover basis

Comprehensive
TPF&T
TPO

Registration number

Vehicle make/model

Overnight parking postcode

Overnight parking

Roadside
Driveway
Garaged
Car Park

Year first registered (yyyy)

Purchase date of vehicle

Value (£)

Vehicle body type

Number of seats

Vehicle annual private mileage

Vehicle annual business mileage

Modified

Type of modification

Modification due to medical condition

Vehicle registered keeper

Yes
No

Vehicle owner

Yes
No

Previously insured

Yes
No

Previous insurer

Claimed previous insurer

Yes
No

NCB years

Protected NCB requested

Yes
No

NCB type (If N/A, use Private Car Bonus)

Private
Company Car
None

Drivers

We need to ascertain number of drivers, then get the prospect to complete the following for each of the drivers. First one should always default to proposer: -

Relationship to proposer

Class of use

Driver title

Drivers Name

Driver date of birth

Years resident in UK

Driver gender

Driver marital status

Driver licence type

Driver licence valid from

Number of other vehicles driven

Driver occupation

Medical condition notifiable to the DVLA

Have any of these conditions caused the driver's licence to be restricted?

Comments

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