URGENT NOTICE —In light of the impact that Coronavirus (COVID-19) we have made the decision to close the public facing office doors until further notice. We continue to offer insurance as normal via the telephone on 832042, our website www.manxcover.com or email us at [email protected] * WORKING HOURS - 9AM - 4PM MONDAY - FRIDAY *

Insured Personal Info

You must be 21 or over

Insurance Refusals

Required as you answered yes to "Have you ever had insurance refused?"

Criminal Convictions

Required as you answered yes to "Any criminal convictions?"

Medical Conditions

Required as you answered yes to "Any medical conditions?"

Non Rating Information

If you provide a contact email address we will email you confirmation when you submit this form

Vehicle Details
Vehicle Modifications

Required as you answered yes to "Any Vehicle modifications?"

Additional Driver 1

You must be 21 or over

Additional Driver 2

You must be 21 or over

Additional Driver 3

You must be 21 or over

Additional Driver 4

You must be 21 or over

If yes, please fill in the details below.

Accidents/Claims/Incident Details 1

If yes, please fill give the cost below.

You can provide details of the circumstances.

Accidents/Claims/Incident Details 2

If yes, please fill give the cost below.

You can provide details of the circumstances.

Accidents/Claims/Incident Details 3

If yes, please fill give the cost below.

You can provide details of the circumstances.

Accidents/Claims/Incident Details 4

If yes, please fill give the cost below.

You can provide details of the circumstances.

Accidents/Claims/Incident Details 5

If yes, please fill give the cost below.

You can provide details of the circumstances.

If yes, please fill in the details below.

Convictions 1

Full details of the reading, ie. Blood, Urine.

Convictions 2

Full details of the reading, ie. Blood, Urine.

Convictions 3

Full details of the reading, ie. Blood, Urine.

Convictions 4

Full details of the reading, ie. Blood, Urine.

Convictions 5

Full details of the reading, ie. Blood, Urine.

Additional Information

Note: NCB can only be used on one vehicle at a time and must be less than 24 months old.

Previous Insurance
Legal Agreements

You must confirm that you have understood and agree to the information supplied on this form.

Please read our Terms of Business and Privacy Notice and Data Policy
(links open in a new window)