Motor Home Quotation
Wise Insurance Services Limited
30 South Parade
Mollison Way
Edgware
Middlesex
HA8 5QL

020 8905 6000

Please print the completed form before pressing the Enter key or clicking on the Submit form button.

DEALER DETAILS

Dealer number: Dealer name:

PROPOSER DETAILS

Title:
First Name:
Surname:
Address:
Post Code:
Telephone:
Mobile:
Email:
Date of birth:
Age:
Sex: Male: Female:
Cover start date:
Cover level:
Licence type:
Licence held for: yrs mths
Homeowner: Yes: No:
Residency Date:
Occupation:
Business:
Employment Status:
VAT registered: Yes: No:
Any convictions/bans: Yes: No:
Details:
Any claims: Yes: No:
Details:

VEHICLE RISK DETAILS

Cover:
Vehicle make and model:
Vehicle length:
Vehicle width:
Engine size (cc):
Vehicle kept postcode:
Where kept overnight:
Left hand drive: Yes: No:
Self built: Yes: No:
Only vehicle: Yes: No:
Annual mileage:
Present mileage:
Vehicle value:
Year:
Alarm/Immobiliser:
Tracking details:
Own motor home yrs:
Registration No.:
Foreign use per year:
Modifications:
Driving restrictions:
Vehicle use:
Voluntary Excess:
Club membership: Yes: No:
NCB years on car:
Protected: Yes: No:
Details:

ADDITIONAL DRIVERS

Driver 2
Name:
Date of birth:
Age:
Licence type:
Occupation:
Business:
Employment Status:
Residency date:
Any convictions/bans: Yes: No:
Details:
Any claims: Yes: No:
Details:
Driver 3
Yes: No:
Yes: No:
Driver 4
Yes: No:
Yes: No: