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Yellow Bolts - High Net Worth Motor Insurance Proposal Form
PLEASE ANSWER ALL QUESTIONS HONESTLY, ACCURATELY AND TO THE BEST OF YOUR KNOWLEDGE. The answers you provide will form the basis of your insurance quotation. If you are unsure about what is relevant, please let us know as it may influence the insurer’s decision to accept the risk or could impact the terms of cover.
If you fail to disclose or misrepresent any information, this could invalidate the policy and mean that claims may not be paid or not paid in full. Any deliberate or reckless non-disclosure may mean that the insurer can void the policy and retain the premium. This applies when you take out a policy, during the term of the policy and when you renew.
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1. Proposer Details
Inception date required
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MM
/
DD
/
YYYY
Title
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Mr
Mrs
Ms
Miss
Dr
Prof
Other
Full name
*
Your answer
Date of birth
*
Your answer
Contact number
*
Your answer
Email address
*
Your answer
Are you a UK resident?
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Yes
No
If not, country of residence
Your answer
Correspondence address
*
Your answer
Occupation / profession
*
Your answer
Employer / business name
Your answer
2. Licence & Driving Profile
Driving licence type
*
Your answer
How long have you held your licence?
*
Your answer
Any motoring convictions in the past 5 years?
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Yes
No
If yes, please provide details
Your answer
Any accidents or claims in the past 5 years?
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Yes
No
If yes, please provide details
Your answer
Any driving disqualifications or suspensions?
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Yes
No
If yes, please provide details
Your answer
Any drivers with overseas licences?
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Yes
No
If yes, please provide details
Your answer
3. Vehicle Details
Registration number
*
Your answer
Make
*
Your answer
Model
*
Your answer
Year of manufacture
*
Your answer
Current estimated value
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Your answer
Date purchased
Your answer
Purchase price
Your answer
Is the vehicle owned, leased, financed or held by company?
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Owned
Leased
Financed
Company owned
If financed, leased or company owned, please provide details
Your answer
Is the vehicle modified from manufacturer standard specification?
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Yes
No
If yes, please provide full details
Your answer
Is the vehicle imported?
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Yes
No
Is the vehicle left hand drive?
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Yes
No
Is the vehicle high performance, prestige, classic or collector?
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Yes
No
If yes, please provide details
Your answer
4. Usage & Travel
Use of vehicle
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Social, domestic and pleasure
Commuting
Business use
Executive use
Chauffeur use
If business, executive or chauffeur use, please provide details
Your answer
Estimated annual mileage
*
Your answer
Will the vehicle be driven abroad?
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Yes
No
If yes, please provide destinations and frequency
Your answer
Will the vehicle be used at track days, rallies or organised motoring events?
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Yes
No
If yes, please provide details
Your answer
5. Drivers
Please provide all drivers to be insured
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Include full name, date of birth, relationship to proposer, occupation, licence type, years licence held, and any claims/convictions.
Your answer
Any named drivers under age 30?
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Yes
No
Any household members not to be insured but with access to the vehicle?
*
Yes
No
If yes, please provide details
Your answer
Will any staff, chauffeurs or employees drive the vehicle?
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Yes
No
If yes, please provide details
Your answer
6. Security & Storage
Main overnight parking address
*
Your answer
Where is the vehicle normally kept overnight?
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Locked garage
Secure underground parking
Gated driveway
Driveway
Private car park
On street
Other
Does the vehicle have an alarm or immobiliser?
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Yes
No
If yes, please provide details
Your answer
Does the vehicle have a tracker?
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Yes
No
If yes, please provide details
Your answer
Is the tracker subscription current and active?
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Yes
No
Is the vehicle ever stored at another location or residence?
*
Yes
No
If yes, please provide details
Your answer
7. Fleet / Collection
Do you own or insure multiple vehicles?
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Yes
No
If yes, please provide details
Your answer
Do you require cover on a multi-vehicle basis?
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Yes
No
Do you own any classic, collector, supercar or specialist vehicles?
*
Yes
No
If yes, please provide details
Your answer
8. Cover Required
Type of cover required
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Comprehensive
Third party fire & theft
Third party only
Do you require agreed value cover?
*
Yes
No
Do you require new vehicle replacement cover?
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Yes
No
Do you require breakdown cover?
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Yes
No
Do you require courtesy car cover?
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Yes
No
Do you require legal expenses cover?
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Yes
No
Do you require European or worldwide cover?
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Yes
No
Do you require protected no claims bonus?
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Yes
No
Number of years no claims bonus
Your answer
Do you require driving other cars cover?
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Yes
No
Do you require cover for personal effects in the vehicle?
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Yes
No
9. Insurance, Convictions & Financial History
Current insurer
Your answer
Current premium
Your answer
Has any insurance held by you or any named driver ever been declined, cancelled, voided or had special terms imposed?
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Yes
No
If yes, please provide full details
Your answer
Have you or any named driver ever been convicted of any criminal offence (other than motoring offences already disclosed)?
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Yes
No
If yes, please provide details including the nature of the offence, date and outcome
Your answer
Have you or any named driver ever been declared bankrupt, entered into an Individual Voluntary Arrangement (IVA), had a County Court Judgment (CCJ), or been subject to any similar financial arrangement?
*
Yes
No
Any additional information that may be relevant
Your answer
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