	Gothic Insurance Brokers Ltd Gothic House Station Rd, Old Harlow Essex CM17 0AP Tel – 01279 429024 Fax – 01279 433383 Email – enquiries@gothicinsurance.com

or call

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

Taxi Insurance Quote

Quotes emailed to you within1 hour (during office hours)

Where did you hear about us?

If other please specify:

Private or Public Hire?

About you
Title
First Name(s)
Surname
Full Address (If vehicle is not kept at this address please state so in additional information section)
Home Postcode
Taxi Base Postcode Area
Email Address
Telephone Number
Sex
UK resident since birth? If 'no' how many years?	Yes No
Date of Birth
Full or Part Time Taxi Driver?
Give details of any other occupations
Employment Status
Marital Status
Are you a Homeowner?
Type of Licence
Have long have you held full licence?
Number of years Taxi experience
Number of continuous years Taxi Badge held
Badge Number (if known)
Name of Licencing Authority?

Vehicle details
Make
Model
Type
Transmission
Fuel type
Body type If Minibus or MPV Please state no. of seats including driver
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? Is the bonus Taxi bonus? If bonus is from a private car insurance- is it available to be used on this policy?
Protected bonus required?
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?
Number years Taxi Badge held?
Badge Number (if known)

Additional Drivers : 2nd Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Number years Taxi Badge held?
Badge Number (if known)

Additional Drivers : 3rd Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Number years Taxi Badge held?
Badge Number (if known)
Additional Drivers : 4th Named Driver
Full Name
Date of Birth
Sex
Occupation
Marital Status
Type of Licence
How Long Licence held?
Number years Taxi Badge held?
Badge Number (if known)

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?

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