Motor Insurance Quote Name sex Male   Female Date of Birth: Address Post Code eMail Telephone Mobile Person to contact Best time for contact? Employment status Employee Company Director Disability Employed Household Duties Independent Means Retired Self Employed Student Unemployed Voluntary Work Occupation Licence type Full UK Provisional UK Foreign E.E.C.C International Restricted >3 Restricted <3 Licence years Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years More than 9 years Any claim in last 3 years? Yes  No Details of any claim in last 3 years Any convictions in last 5 years? Yes  No Details of any convictions in last 5  years Vehicle make Aixam Alfa Romeo Allard Alvis Amc Arm Siddeley Aro Asia Aston Martin Audi Austin Auto Union Bentley Bitter Bmw Bond Borgward Bristol Bugatti Buick Cadillac Caterham Chevrolet Chrys Aus Chrysler Citroen Colt Daewoo Daf Daimler Dallas Datsun De Tomaso Delorean Era Facel Vega Fairthorpe Ferrari Fiat Ford Ford (Aus) Ford (Ger) Ford (Usa) Fso (Polski) Gilbern Ginetta Goggomobil Hillman Honda Humber Hyundai Iso Rivolta Isuzu Jaguar Jeep Jensen Jowett Khaleej Kia Lada Lamborghini Lanchester Lancia Landrover Lexus Ligier Lincoln Lonsdale Lotus Mahindra Marcos Maserati Mazda Mcc Mercedes Mercury Mg Mitsubishi Morgan Morris Moskvich Nissan Nsu Opel Panhard Panther Perodua Peugeot Porsche Portaro Proton Reliant Renault Riley Rolls Royce Rover Saab Sao Seat Simca Singer Skoda Ssangyong Standard Subaru Sunbeam Suzuki Talbot Tata Toyota Triumph Tvr Valiant Vanden Plas Vauxhall Volga Volkswagen Volvo Wartburg Wolseley Zastava Vehicle model Vehicle style 2 door coupe 2 door saloon 2 door convertible 3 door hatchback 3 door coupe 3 door estate 4 door saloon 5 door hatchback 5 door estate Gearbox Manual Automatic Fuel Petrol Diesel Electric Hybrid Petrol Hybrid Diesel Engine size Drive side Left  Right Vehicle value Vehicle modified Yes  No Vehicle alarm None fitted Thatcham category 1 Thatcham category 2 Unapproved alarm Unapproved immobiliser Unapproved alarm/immobiliser Manufacturer standard fitted security UK registered Yes  No Vehicle registration no Purchase date Normal storage Parked on drive Kept on public road Garaged Kept on private property Car park Postcode kept Annual business miles Annual total miles Year of manufacture Cover date Use required Social Domestic and pleasure (excl. to and from work) SD&P (incl. to and from work) SD&P plus business use SD&P plus business use for others Level of cover Comprehensive Third party fire and theft Third party only Voluntary excess No excess 50 100 200 300 400 500 No claims bonus protection Yes  No Years no claim Legal protection Yes  No Additional driver: None 1 2 Registered owners Proposer Relative Other Additional driver 1 Additional driver 2 Who will drive Insured only Insured and spouse only Insured and additional driver(s) Any Licenced driver over 25 Main driver Proposer Additional driver 1 Additional driver 2 DRIVER 1    (Leave blank, if no additional drivers) Relationship Spouse Relative Friend Other Other vehicle Yes  No Title Mr Mrs Ms Miss Dr Forename Surname Sex Male  Female Date of birth Employment status Employee Company Director Disability Employed Household Duties Independent Means Retired Self Employed Student Unemployed Voluntary Work Occupation Licence type Full UK Provisional UK Foreign E.E.C.C International Restricted >3 Restricted <3 Licence years Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years More than 9 years Any claim in last 3 years? Yes  No Details of any claim in last 3 years Any conviction in last 5 years? Yes  No Details of any convictions in last 5  years ADDITIONAL DRIVER 2    (Leave blank, if no additional drivers) Relationship Spouse Relative Friend Other Other vehicle Yes  No Title Mr Mrs Ms Miss Dr Forename Surname Sex Male  Female Date of birth Employment status Employee Company Director Disability Employed Household Duties Independent Means Retired Self Employed Student Unemployed Voluntary Work Occupation Licence type Full UK Provisional UK Foreign E.E.C.C International Restricted >3 Restricted <3 Licence years Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years More than 9 years Any claim in last 3 years? Yes  No Details of any claim in last 3 years Any conviction in last 5 years? Yes  No Details of any convictions in last 5  years Comments   WHITE KNIGHT GROUP Britannia House High Street Bream, Lydney Glos GL15 6JS Tel 01594 563288 Fax 01594 564084 Email janeclark@whiteknightgroup.co.uk FSA number is 121356 White Knight Group is an independent intermediary authorised and regulated by The Financial Services Authority who also trade under the names of Dean Magna Insurance & Financial Consultants, Farmer & Clark Insurance & Financial Consultants and Swambo Woollett Insurance & Financial Consultants. Please refer to www.fsa.gov.uk for further information.

Data Protection Any personal or financial information supplied to The Group may be stored, used and transmitted to Insurers,Brokers,credit Reference Agencies and Financial Services Institutions in the context of advising/making recommendations on, and arranging transactions and related credit facilities in, General Insurance business on your behalf. Insurers share information with each other via the “Claims and Underwriting Exchange Register” and the “Motor Insurance Anti-fraud and Theft Register” to aid the prevention of fraudulent claims. Disclosure of Material Facts Please advise White Knight Group immediately if any information contained herein is incorrect. This Statement of Fact forms the basis of the Insurance contract. A Material Fact is one likely to influence an Insurer in the assessment and acceptance of the Insurance. All material facts known to you should be disclosed. Should you be in doubt whether or not a fact is material, it should be disclosed for your own protection, since failure to disclose a material fact may invalidate the Policy.

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