TCIS Insurance
Personal Info
Vehicle Details
DONE!
Owner Details
Registered Owner's Name:
Date of Birth:
Driving Experience:
Is there more than 1 owner?
Yes No
Will there be any other drivers?
(of this vehicle)
Yes No
Contact Details
Mobile:
Home Phone:
Work Phone:
Fax:
Email:
Best Point of Contact:
Driver History
Has, or is, any regular driver(s):
Under 21 years of age?
Yes No
Lost their licence in the last 5 years?
Yes No
Had motor insurance declined, cancelled or renewel refused?
Yes No
Had any motor claims or other losses in the last 5 years?
Yes No
Had any insurer require special terms?
Yes No
Used/ing the vehicle in any business or commercial activities?
Yes No
Been charged, convicted or penalised for any motoring offences?
Yes No
Been charged or convicted of any criminal offences in the last 10 years?
Yes No
Are there any exceptional circumstances relating to the risk, which may
Yes No
affect our decision to insure you?
If YES to any of the above, please provide details: