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Specialist Vehicle Quotation Fact Finder Form
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Client Details
Title
Mr
Ms
Mrs
Miss
Mx
Client name
Contact Telephone Number
Email
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Date of Birth
DD slash MM slash YYYY
Address
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Street Address
Address Line 2
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Brazil
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Cameroon
Canada
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Central African Republic
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China
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Congo, Democratic Republic of the
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Cyprus
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Favoured Charity
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Brent Lodge Wildlife Hospital
Bumblebee Conservation Trust
Buglife
Butterfly Conservation
Cuan Wildlife Rescue
David Shepherd Wildlife Rescue
Dean Farm Trust
Froglife
Global Wildlife Rescue Project
Helping Rhinos
International Otter Survival Fund
Just One Ocean
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Play For Strays
SEED Madagascar
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The Vegan Society
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St Mungo's
Vehicle Details
Which type of Vehicle would you like a quote for?
Please Select
Off Road 4x4
Classic Car
Classic Bike
Campervan
Horsebox
Vehicle Make
Registration No
Purchase Date
Day
Month
Year
Model
CC
Registration Date
Day
Month
Year
Driving Position
Please Select
Left Hand Drive
Right Hand Drive
Annual Mileage
Value
Alarm Type
Number of Seats
Please Select
2
3
4
5
6
7
Tracker Type
Immobiliser Type
Registered Keeper
Overnight Parking
Please Select
Garage
Drive
Road
Other
If other, please Specify
Owner
Proposers Details
Name
D.O.B
Day
Month
Year
Sex
Please Select
Female
Male
Marital Status
Main User
UK Resident From
Licence
Please Select
Full
Provisional
Date Obtained
Day
Month
Year
Pass Plus
Please Select
Yes
No
Main Occupation
Employment Status
Convictions?
Please Select
Yes
No
Medical Conditions?
Claims?
Please Select
Yes
No
DVLA Notified about Condition?
Pending Prosecutions?
Insurance Refused?
Dishonesty Convictions?
Cover Details
Target Premium
Cover Requested From
Day
Month
Year
Cover Required
Please Select
Comprehensive
Third Party Fire & Theft
Third Part Only
Years No Claims Bonus
Cover required for Travelling to & from Work
Yes
No
Do you have an everyday use vehicle?
Yes
No
Renewal Date
Day
Month
Year
What modifications does your vehicle have?
Is your vehicle used for off roading?
Yes
No
Is your vehicle used for green lanning?
Yes
No
Are you looking for an agreed value?
Yes
No
Have you had an independent valuation?
Yes
No
Are you a member of an owners club?
Yes
No
What is the name of the club?
Are you looking for wedding hire cover?
Yes
No
How many weddings do you intend to do each year?
Additional Driver Details if Any
Please provide details of any accidents, claims and convictions below
Would you like to add any additional drivers?
Please Select
No
One
Two
Three
Additional Driver 1
Name
D.O.B
Day
Month
Year
Sex
Please Select
Female
Male
Marital Status
Main User
UK Resident From
Licence
Please Select
Full
Provisional
Date Obtained
Day
Month
Year
Pass Plus
Please Select
Yes
No
Main Occupation
Employment Status
Convictions?
Please Select
Yes
No
Medical Conditions?
Claims?
Please Select
Yes
No
DVLA Notified about Condition?
Pending Prosecutions?
Insurance Refused?
Dishonesty Convictions?
Additional Driver 2
Name
Sex
Please Select
Female
Male
D.O.B
Day
Month
Year
Marital Status
Main User
UK Resident From
Licence
Please Select
Full
Provisional
Date Obtained
Day
Month
Year
Pass Plus
Please Select
Yes
No
Main Occupation
Employment Status
Convictions?
Please Select
Yes
No
Medical Conditions?
Claims?
Please Select
Yes
No
DVLA Notified about Condition?
Pending Prosecutions?
Insurance Refused?
Dishonesty Convictions?
Additional Driver 3
Name
D.O.B
Day
Month
Year
Sex
Please Select
Female
Male
Marital Status
Main User
UK Resident From
Licence
Please Select
Full
Provisional
Date Obtained
Day
Month
Year
Pass Plus
Please Select
Yes
No
Main Occupation
Employment Status
Convictions?
Please Select
Yes
No
Medical Conditions?
Claims?
Please Select
Yes
No
DVLA Notified about Condition?
Pending Prosecutions?
Insurance Refused?
Dishonesty Convictions?
Details of any claims
Driver Name
Date
Day
Month
Year
Circumstances
Driver Name
Date
Day
Month
Year
Circumstances
Driver Name
Date
Day
Month
Year
Circumstances
Details of any Motoring Convictions
Driver Name
Conviction Date
Day
Month
Year
Conviction Code
Driver Name
Conviction Date
Day
Month
Year
Conviction Code
Driver Name
Conviction Date
Day
Month
Year
Conviction Code
Home Insurance
When is your home insurance due?
Day
Month
Year
We will only use the information submitted in this form to make contact with you regarding your enquiry. Your details will be stored securely and will never be passed to third parties outside of the quoting for and arrangement of your insurance or communications from Evergreen. Please tick the box to confirm you are happy with this.
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