Tractor Quotation Form

Have you or any person who may drive had any accident, loss or claim (whether or not to blame) in connection with any motor vehicle within the last 5 years?*

Yes

Please provide details of each incident.
(Drivers Name, Registration No, Date of Loss, Description, Cost)

Motoring Convictions

Have you or any person who may drive, ever been convicted of any motoring offence within the last 5 years (including fixed penalty notices)?

Yes

Please provide details of each incident.
(Drivers Name, Date of Conviction, Conviction Code, No. of Points, Fine Amount, Length of Ban)

Medical

Have you or any person who may drive suffered or currently suffer from a medical condition or disability, which is notifiable to the Driver and Vehicle Licencing Agency (DVLA)?

Yes

General

Have you or has any business in which you were director had their insurance cancelled or been refused renewal terms by insurers?

Yes

Have you or any of your employees ever been convicted of or charged (but not yet tried) with any criminal offence (other than motoring offences)?

Yes

Have you ever been declared bankrupt or insolvent or has any business in which you were a director or involved in management gone insolvent or into liquidation, administration receivership or entered into an arrangement with creditors?

Yes

Have you ever been prosecuted under the Health and Safety at Work Act or other legislation relating to health and safety at work or corporate manslaughter?

Yes

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Proposer:

Existing Insurer:

Tractor Details:

Use

Accidents/Claims

Motoring Convictions

Medical

General

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How we use your information

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