Car Insurance – Quotix Motor Insurance

Call: 0330 113 1733

Opening Time:

10:00 am to 6:00 PM Monday to Saturday

CAR INSURANCE - FORM

Application Details

Application Method:

Online Phone

How did you hear about us?

Leaflet Friend or Family Existing Customer Social Media

Have you or any listed drivers ever had an insurance policy declined, cancelled, or issued with special terms? *

Yes No

"We are registered with the Information Commissioner's Office (ICO), and all personal data is processed in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018."

Personal Information

Title: *

First Name: *

Middle Name (Optional)

Last Name: *

Date of Birth: *

House Number / Name: *

Street Address: *

Postcode: *

Were you born in the UK? *

Yes No

Employment Status: *

Occupation:

Type of Business / Industry:

Marital Status: *

Are you a homeowner?

Yes No

Do you have any children under 16 years old?

Yes No

Contact Information

Email Address: *

Home Telephone Number:

Mobile Number: *

License & Driving History

Type of Driving Licence: *

How long have you held your licence? *

If less than 3 years, please specify the date obtained:*

16-character Driving Licence Number: This may reduce your price

Do you have any DVLA-declared medical conditions or disabilities? *

Do you drive or have access to any other vehicles?*

Do you have any non-motoring criminal convictions?

Yes No

Motor Accidents or Claim Details

Have you had any motor accidents, claims (fault or non-fault), or incidents in the last 5 years? *

Yes No

1 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries :

Yes No

2 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries :

Yes No

3 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries :

Yes No

Motor Conviction, Fixed Penalty or Disqualification Details

Have you received any motoring convictions, fixed penalties, or disqualifications in the last 5 years? *

Yes No

1 Conviction Code: Date of Conviction: Points: Fine(£) - if any: Ban(months) - if any:

2 Conviction Code: Date of Conviction: Points: Fine(£) - if any: Ban(months) - if any:

3 Conviction Code: Date of Conviction: Points: Fine(£) - if any: Ban(months) - if any:

Vehicle Details & Usage

Vehicle Registration Number: *

Current Market Value (£): *

Does the car have a dashcam?

Yes No

Does the vehicle have any modifications?

Yes No

Date of Vehicle Purchase: *

Purpose of Use:*

Where is the vehicle kept during the day? *

Where is the vehicle kept overnight? *

Is the vehicle kept at your home address? *

Yes No

NOte :If no, please provide the full address:

Registered Keeper: *

Legal Owner: *

Is the car impounded with the police?

Yes No

Estimated Annual Mileage: *

Type of Cover Required: *

No Claims Discount (NCD)

Do you have a No Claims Discount (NCD)? *

Yes No

Preferred Voluntary Excess: *

How do you normally pay for insurance?

Monthly Annually

Preferred Policy Start Date: *

Current or Previous Insurer’s Name:

Your Existing Insurance Renewal/Current Quote Amount (£):

Additional Drivers If Any

Would you like to include an additional driver on the policy? *

Yes No

Additional Driver 1 – Personal Information

Title: *

First Name: *

Middle Name (Optional)

Last Name: *

Date of Birth: *

Were you born in the UK? *

Yes No

Employment Status: *

Occupation:

Type of Business / Industry:

Marital Status: *

Relationship to Policyholder? *

Are you a homeowner?

Yes No

Do you have any children under 16 years old?

Yes No

Additional Driver 1 – Licence & Driving History

Type of Driving Licence: *

How long have you held your licence? *

If less than 3 years, please specify the date obtained:*

16-character Driving Licence Number: This may reduce your price

Do you have any DVLA-declared medical conditions or disabilities? *

Do you drive or have access to any other vehicles?*

Do you have any non-motoring criminal convictions?

YES NO

Motor Accidents or Claim Details

Have you had any motor accidents, claims (fault or non-fault), or incidents in the last 5 years? *

Yes No

1 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries :

Yes No

2 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries :

Yes No

3 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries :

Yes No

Motor Conviction, Fixed Penalty or Disqualification Details

Have you received any motoring convictions, fixed penalties, or disqualifications in the last 5 years? *

Yes No

1 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

2 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

3 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

Motor Accidents or Claim Details

Have you had any motor accidents, claims (fault or non-fault), or incidents in the last 5 years? *

Yes No

1 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries : Yes No

2 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries : Yes No

3 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries : Yes No

Motor Conviction, Fixed Penalty or Disqualification Details

Have you received any motoring convictions, fixed penalties, or disqualifications in the last 5 years? *

Yes No

1 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

2 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

3 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

Motor Accidents or Claim Details

Have you had any motor accidents, claims (fault or non-fault), or incidents in the last 5 years? *

Yes No

1 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries : Yes No

2 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries : Yes No

3 Type : Date : Damage : Cost(£) - if known : Fault : Any Injuries : Yes No

Motor Conviction, Fixed Penalty or Disqualification Details

Have you received any motoring convictions, fixed penalties, or disqualifications in the last 5 years? *

Yes No

1 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

2 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

3 Conviction Code: Date of Conviction: Points: Fine(£) - if any : Ban(months) - if any :

Additional Comments:

(Please provide any further details or special requests here.)

With our stated Terms and Conditions & Privacy Policy

By clicking 'Submit', you provide your explicit consent for us to process the information you have provided in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. This data will be used solely for the purpose of sourcing the most competitive quote and may be shared with selected partners across both online and offline markets.

Call: 0330 113 1733

CAR INSURANCE - FORM

Motor Accidents or Claim Details

Motor Conviction, Fixed Penalty or Disqualification Details

Additional Driver 2

Motor Accidents or Claim Details

Motor Conviction, Fixed Penalty or Disqualification Details

Additional Driver 3

Motor Accidents or Claim Details

Motor Conviction, Fixed Penalty or Disqualification Details