Gothic Insurance Brokers Ltd
Gothic House
Station Rd, Old Harlow
Essex CM17 0AP

Tel – 01279 429024
Fax – 01279 433383
Email – enquiries@gothicinsurance.com

Private Car Insurance Quote

(with criminal convictions)

Where did you hear about us?

If other please specify:

About you
Title
First Name(s)
Surname
Full Address (If vehicle is not kept at this address please state so in additional information section)
Postcode
Email Address
Telephone Number
Sex
Date of Birth
Occupation
Type of business
Employment Status
Marital Status
Are you a Homeowner?
Type of Licence
Have long have you held full licence?

About your convictions	(please list 1,2,3 in each section if you have more than 1 conviction)
Date of Offence
Date of Conviction
Type of Conviction (e.g GBH, Common Assault)
Sentence given by court (e.g. 5 years custodial or 100 hrs community service)
Sentence actually served (e.g. served 2 years then 3 months on tag)
Description of Incident (Please give as much information as possible)
Mitigating Circumstance (e.g. had drink problem at time now recovering alcoholic etc.)
Vehicle details
Make
Model
Type
Transmission
Fuel type
Body type
Year Car First Registered
Registration number (if known)
Engine Size
Current Value
Date of Purchase
Where is the vehicle kept overnight?
Are you the registered owner & keeper?

Cover Required
Cover required
How Many years no claims bonus do you have on this vehicle?
Protected / Guaranteed bonus required?
If you have no bonus please give any details of driving experieince over last 5 years. NB: Proof of Experience may be required	e.g. Named drvier for 5 years on spouses policy e.g. Company car driver for 5 years
Use of vehicle
What is your approximate annual mileage for :
Pleasure Use
Business Use
Who will drive the vehicle?
Please state name of MAIN driver

Additional Drivers : 1st Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?

Additional Drivers : 2nd Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?

Additional Drivers : 3rd Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?
Additional Drivers : 4th Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Relationship to you?

Accidents / Convictions

Please give FULL details below of any claims against your policy or on the records of named drivers in the last FIVE years. (Please include Date, any injuries, whether bonus was affected)

Please also list below any motoring convictions for yourself or any named drivers in the last FIVE years. (Please include Dates of convictions, conviction codes, fines/penalty points & any bans incurred)

Additional Information
Please add any information you feel may affect the quotation.

How would you like to be contacted?

01279 429024

Authorised & Regulated by the
Financial Service Authority
Firm Number: 300031

Gothic Insurance Brokers Ltd. is registered in England. Company Reg. Number 880423. Registered Office: Gothic House, Station Rd, Old Harlow, Essex CM17 0AP