Hencilla Canworth
Contact us

Request a quote for Private Car Insurance

Please complete and return this questionnaire so we can apply to our panel of insurers for a quote on your behalf. If you have a query regarding how to answer any of the questions please call us on 020 8686 5050.

After submission of the form it may be necessary for us to contact you for additional information to secure a quotation. The information provided will form the basis of your contract with the insurers so it is important that it is accurate.

If you provide false or inaccurate information, withhold information or fail to Private car quote inform us of any relevant details the policy issued could be cancelled, declared void or the insurers could refuse to pay a claim.

You, Proposer
Your Car or Van (Van should be under 3.5 ton)
Drivers

You must provide details of yourself and any other person who may drive your car. You must also disclose the details of any medical conditions or disabilities that must be notified to the DVLA, whether the driving license has been restricted or not we may request a copy of your driving license following a claim.

Convictions

In the last five years, have you or any person who may drive been convicted of any motor offences (including fixed penalties) been disqualified from driving or are there any prosecutions pending

PLEASE PROVIDE THE DETAILS BELOW. Any additional information that cannot fit please use the Any additional information about you or the vehicle in the very last box.

Accidents/Claims/Losses

Have you or any person who may drive had any accidents/claims/losses (whether to blame or not) in connection with ANY motor vehicle during the last five years?

PLEASE PROVIDE THE DETAILS BELOW. Any additional information that cannot fit please use the Any additional information about you or the vehicle in the very last box.

Non-motoring Convictions

Has anyone who may drive been convicted or charged (but not tried) of any non-motoring offences IF YES give details below.

Insurance History/Renewal
Additional Details

* Required.