Motor Enquiry - Bishop Calway Insurance Services LTD & Peter S.Taylor & Co

1 Your Details

2 Vehicle Details

3 Driver Details

4 Claims & Convictions

This form should take no more than 10 minutes to complete. If you need help or have any questions, please do not hesitate to call us on:
Tel: 01273 820303
All fields are required. Your information will be used only for the purpose of this form and will not be passed or sold onto 3rd parties without your permission. To find out more you can view our Privacy Policy.
Your Details:
Title*
First Name*
Last Name*
Address*
Street Address Address Line 2 City County / State / Region Post Code Country
Date of Birth*
Email*
Telephone*
Employment Status*
Occupation*
Business*
Club Member*
How did you hear about us?*

Driver Details
Drivers*
Other Driver Details:
Driver Name Date of Birth Gender Occupation Business Licence Held UK Test Passed Actions
Edit
Delete
There are no Drivers.
Maximum number of drivers reached.
Do you or any driver have any disability or medical condition that needs to be disclosed to the DVLA that has not been notified to them?*
- No
- Yes
Have you or any driver ever been convicted of any non-motor criminal offence, or have any criminal prosecutions pending? Convictions spent under the Rehabilitation of Offenders Act 1974 are excluded*
- No
- Yes
Do all drivers hold a full UK or EU licence for 2+ years?*
- No
- Yes
Have you or any driver ever been refused insurance or had special terms imposed, had cover cancelled or declined?*
- No
- Yes

Claims
Have you or any driver had any accident(s), claim(s) or loss within the last 5 years irrespective of blame?
- No
- Yes
Claims
Driver Name Fault Date Details Own Costs 3rd Party Costs Actions
Edit
Delete
There are no Claims.
Maximum number of claims reached.
Convictions
Have you or any driver had any motoring convictions or fixed penalty notices in the last 5 years?*
- No
- Yes
Do you or any driver have any pending motoring convictions or any pending fixed penalty notices?*
- No
- Yes
Driver Convictions
Driver Name Offence Date Fine Ban Actions
Edit
Delete
There are no Convictions.
Maximum number of convictions reached.
Name
This field is for validation purposes and should be left unchanged.

Driver Name	Date of Birth	Gender	Occupation	Business	Licence Held	UK Test Passed	Actions
							Edit Delete
There are no Drivers.

Driver Name	Fault	Date	Details	Own Costs	3rd Party Costs	Actions
						Edit Delete
There are no Claims.

Driver Name	Offence	Date	Fine	Ban	Actions
					Edit Delete
There are no Convictions.

Motor Enquiry Form