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Car Insurance Quotation

For a free quotation on car insurance please complete the short form below.  One of our advisors will contact you via your preferred method with your quotation.

To make sure you get our best deal and to ascertain the most appropriate payment options for you and to protect you from fraud, we use public and personal data from a variety of sources, including a credit reference agency and other organisations. Our search will appear on your credit report whether or not your application proceeds. By continuing you agree to these uses of your information.

Personal Details
To make sure you get the best deal, please complete your full name and not just initials
Title:
Forename(s)
Surname
Date of Birth         
Marital Status
House Name/Number
Street Name
Town
City
County
Postcode
Home Telephone No
Work Telephone No
Mobile Telephone No
Email Address
Preferred Method of Contact
   
Vehicle Details
Registration Number
Make of Vehicle
Model (including derivative, eg Golf GTI)
Engine Size
Body Type
Fuel Type
Year of Make
Value
Current Mileage Reading
Who is the owner of the vehicle
Who is the registered keeper of the vehicle?
Where will the vehicle be kept overnight?
   
Cover Details
What cover do you require?
What will the car be used for?
Who would be driving the vehicle?
Are you entitled to any No Claims Discount?
Do you require No Claims Bonus Protection? Yes  No
Do you require RAC Breakdown cover?
Do you require Uninsured Loss Recovery cover? Yes  No
When will you require cover from?

Drivers Details
  Full Name Date of Birth Relationship to Proposer Occupation Licence Type Date Passed Test
Proposer     Proposer
Driver 2  
Driver 3  
Driver 4  
             
Accident/Claims History  
Have any of the above been involved in any accidents or suffered any losses within the last 5 years? Yes  No
(If yes, please give details below)  
Driver Name Incident Date Incident Decription Own Cost (£) Third Party Cost (£) Fault / Non-Fault
     
     
     
     
           
Conviction History  
Have any of the drivers been convicted of any motoring offences within the last 5 years or ever been banned from driving Yes  No
(If yes, please give details below)  
Driver Name Conviction Code Date of Conviction Date of Offence Fine (£) Penalty Points Disqualification Period
         
         
         
         
             
General Questions  
Do you or your family have the use of any vehicles not included above? Yes  No
Have any of the drivers any medical conditions requiring notification to the DVLA? Yes  No
   
Insurance History  
Who is the current insurer?
What is the current premium? £
   
Legal  

I/We understand that where the insurance requires supply of information relating to other persons who may be insured under the contract, that the information must be factual and accurate to enable correct assessment of risk by the insurer. I confirm that I have the consent of these individuals to supply their personal details to the insurer.
For the purposes of the Data Protection Act 1998 the data controller in relation to any personal data you supply is Cox Braithwaite Insurance Brokers.
 I/we understand that the information I/we supply may be used by Cox Braithwaite Insurance Brokers to keep me informed by post, telephone, e-mail or other means about products and services which may be of interest to me. Please note that your information may also be used for these purposes after your policy has lapsed. If you do not wish your information to be used for marketing purposes, please tick this box
Your quotation will be based on the information you have provided above and this information will form the basis of your policy if you decide to buy, please check the information you have entered.

 
  Contact Us
General & Professional Insurance Brokers Ltd t/a Cox Braithwaite Insurance Brokers
Park House
Greyfriars Road
Cardiff, CF10 3AF

Telephone: 0800 975 3322
Fax: 029 2037 3687

   MOTOR INSURANCE
HOME INSURANCE
BUSINESS INSURANCE
TRAVEL INSURANCE
CARAVAN INSURANCE
PROPERTY OWNER'S INSURANCE		    

Company Registration No. 1535804

Copyright © Cox Braithwaite Insurance Brokers 2011

General & Professional Insurance Brokers Ltd t/a Cox Braithwaite Insurance Brokers are Authorised & Regulated by the Financial Services Authority