FCCUK - Neil Willies Insurance Brokers Ltd

FCCUK - Neil Willies Insurance Brokers Ltd

Personal Details

Title *	House Name/No. *
First Name *	Street *
Surname *	Town/City *
Date of Birth (dd/mm/yyyy) *	County *
email	Post Code *
Contact Number *	UK Resident from Birth *
Marital Status	If No, UK Resident from (dd/mm/yyyy)
Employment Status *
Occupation Incl. Job Title & Employers business

Licence & Cover Details

Licence Type *	Date Cover to Start (dd/mm/yyyy)
Licence held for *	Type of Cover *
Vehicle Use *	No Claims Bonus *
Any DVLA reported medical conditions	Place where vehicle is kept
Annual Mileage	Postcode where vehicle will be kept
How long have you owned the vehicle	Any Convictions in the last 5 years *
Advanced Driving Qualifications	If yes, please state Code(s) & Date(s)
	Have you had any accidents in the last 5 years? If yes, please state
	Do you have access to another vehicle? If yes, please state make and model

Vehicle Details

FCCUK Member No. If non member please type none *	Is vehicle RHD or LHD *
Vehicle Registration No. *	Is vehicle UK manufactured
Vehicle Model *	Is the vehicle currently insured *
Vehicle Value	If yes, who with
Year of manufacture	If no,reason(s) why
Please state any added security, if applicable	Have you already been quoted *
Please state any modifications, if applicable	If yes, how much was the quote
Vehicle BHP

Additional Driver - If Applicable

Title	UK Resident from Birth
First Name	If No, UK Resident from (dd/mm/yyyy)
Surname	Frequency of Use
Date of Birth (dd/mm/yyyy)	Use of another vehicle, If yes please state make and model
Marital Status	Any DVLA reported medical conditions
Employment Status	Advanced Driving Qualifications
Occupation if employed	If applicable, please state any accidents in the last 5 years
Relationship to Main Driver	If applicable, please state any convictions in the last 5 years with code(s) and date(s)
Licence Type	Do you own another vehicle? If yes, please state make, model and no claims bonus earned on this vehicle
Licence held for	Do you have access to another vehicle? If yes, please state make and model