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Please enter the person's details Click to expand/collapse

Title

First Name(s)

Last Name

Date of Birth

UK / IOM Born?

Yes

UK / IOM Residence From?

Politically Exposed Person?

A "PEP" is someone who has a prominent position in life which gives them the power to make or influence major decisions ie an MHK or a Chief Executive of a large company.

Not yet known

Yes

Details

Gender

Female

Male

Not Specified

Marital Status

Civil Partner

Co-habiting

Divorced

Married

Single

Widowed

Not Specified

Occupation

Business Type

Address

Please include the postcode.

Telephone Number

Email Address

Additional policyholder data

No items have been added

Add Item

Please enter the date you'd like the policy to start from in dd/mm/yyyy format Click to expand/collapse

Start Date

Please enter the date you'd like the policy to start from in dd/mm/yyyy format

Main Policyholder Click to expand/collapse

The Policyholder will be a

Not yet known

Main Driver

Regular Driver

Non Driver

Ever been convicted (or charged but not yet tried) of any criminal offence, or received a police caution?

Not yet known

Yes

Conviction details

Been refused insurance or had special terms or conditions applied by an insurer?

Not yet known

Yes

Insurance refusal details

Have you or any member of your family living with you had any insurer decline, cancel or declare void insurance or impose special terms?

Not yet known

Yes

Details

Vehicle Lookup Click to expand/collapse

Match year or engine capacity using the prefixes Y and CC e.g. "CC2936 Y1987"

Please select your vehicle

Does your vehicle differ in any way?

If you couldn't find an exact match to your vehicle then choose the closet one and describe any differences here

Vehicle Details Click to expand/collapse

Do you know the registration number?

Not yet known

Yes

Registration Number

Year of Manufacture

E.g. 2019

Number of Seats

Is the vehicle left hand drive?

Not yet known

Yes

Has the vehicle been modified?

Not yet known

Yes

Modification details

Purchase Date

Price Paid

Estimated Market Value

Vehicle Owner Click to expand/collapse

Who is the registered keeper & owner?

Not yet known

Proposer

Spouse

Company

Leased

Other

Where is the vehicle kept overnight?

Not yet known

Road / Public Highway

Locked Garage

Driveway / Own Private Land

Overnight address

Fill in an Isle of Man address, including the postcode.

Loss / Claim history Click to expand/collapse

Previous claims on insurance policies

Has the proposer or named driver had any accidents, claims or incidents in any vehicle in the last 5 years?

Not yet known

Yes

Claim details

No items have been added

Add Claim

Driving Licences Click to expand/collapse

Please detail all policyholders' driving licences

Licence details

No items have been added

Add Driving Licence

Motoring conviction history Click to expand/collapse

Details of historical motoring convictions

Has the proposer or named driver had any motoring convictions?

Not yet known

Yes

Conviction details

No items have been added

Add Convictions

Medical condition history Click to expand/collapse

Details of medical conditions

Has the proposer or named driver been diagnosed with any reportable medical conditions?

Not yet known

Yes

Medical condition details

No items have been added

Add Medical Condition

Cover Required Click to expand/collapse

Named Drivers

Not yet known

Insured Only

Insured & Spouse

Insured + 1

Insured + 2

Insured + 3

Insured + 4

What level of cover do you require?

Not yet known

Comprehensive

Third Party Fire & Theft

What use class do you require?

Not yet known

Social Domestic and Pleasure

Social Domestic & Pleasure including commuting

Business use excluding deliveries

No Claims Discount Click to expand/collapse

How many years No Claims Discount do you currently have?

Please enter the number of whole years

Do you require No Claims Discount protection?

Not yet known

Yes

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