ManxCover
Van Insurance Application

Company Name:

Are you a Politically Exposed Person?

-- Yes No

Politically Exposed Person: Someone with a prominent position in life which gives them the power to make or influence major decisions.
For example a Politician (i.e. MHK) or a chief executive of a large organisation (i.e. chief executive of a large bank).

Title:

-- Miss Ms Mr Mrs Dr Captain Lady Lord

Forenames:

Surname:

Gender:

-- Male Female

Date of Birth:

You must be 21 or over

Place of Birth:

Marital Status:

-- Married Single Civil Partnered Widowed Divorced

Address:

Post Code:

Property Type:

-- House Flat Licenced Premises

When did you become an IOM/UK resident:

Licence Type:

-- Provisional UK Full UK European International

Date Passed Test:

Contact Tel Number(s):

Occupation:

Employment Status:

-- Employed Houseperson Director Unemployed Self Employed

Employers Business Type:

Have you ever had insurance refused:

No Yes

Any Criminal Convictions:

No Yes

Any Medical Conditions:

No Yes

Reason:

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

Details:

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

Details:

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

Email Address:

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

Target Premium Quote:

Target Insurer:

How did you hear about us:

-- Yellow Pages Recommended (word of mouth) Website Manx Radio Advert Best Business Guide Social Media/Facebook Southern/Northern Chronicle

Make:

Model:

Exact Type:

Year of Manufacture:

Engine cc:

Registration Number:

Estimated Market Value:

Date of Purchase:

Price Paid:

Body Type:

-- Van Tipper Pick Up Flat Back

Manual or Automatic:

-- Manual Automatic

Number of Seats:

-- 2 3 4 5 6 7

Gross Vehicle Weight:

-- Under 2 Tonnes Between 2-3 Tonnes Between 3-3½ Tonnes

Left Hand Drive:

No Yes

ABS Fitted:

-- No Yes

Where kept over night:

-- Road/Public Highway Locked Garage Driveway/Own Private Land

Registered Keeper & Owner:

-- Proposer Spouse Company Leased Other

Access to Other Vehicles by Proposer:

-- Owner Named Driver Company Vehicle None

Number of Vehicles in Household:

-- 1 2 3 4 5 6 7 8 9

Current Vehicle Mileage:

Petrol/Diesel/Electric:

-- Petrol Diesel Electric

Any Vehicle Modifications:

No Yes

Details:

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

Title:

-- Miss Ms Mr Mrs Dr Captain Lady Lord

Forenames:

Surname:

Gender:

-- Male Female

Marital Status:

-- Married Single Civil Partnered Widowed Divorced

Date of Birth:

You must be 21 or over

Place of Birth:

When did they become an IOM/UK Resident:

Licence Type:

-- Provisional UK Full UK European International

Date Passed Test:

Relationship to Proposer:

-- Spouse Civil Partner Commonlaw Spouse Parent Offspring Sibling None

Use of Vehicle:

-- Main User Commuting Use Frequent Infrequent

Access to Other Vehicles by Additional Driver:

-- Owner Named Driver Company Vehicle None

Occupation:

Employment Status:

-- Employed Houseperson Director Unemployed Self Employed

Employers Business Type:

Title:

-- Miss Ms Mr Mrs Dr Captain Lady Lord

Forenames:

Surname:

Gender:

-- Male Female

Marital Status:

-- Married Single Civil Partnered Widowed Divorced

Date of Birth:

You must be 21 or over

Place of Birth:

When did they become an IOM/UK Resident:

Licence Type:

-- Provisional UK Full UK European International

Date Passed Test:

Relationship to Proposer:

-- Spouse Civil Partner Commonlaw Spouse Parent Offspring Sibling None

Use of Vehicle:

-- Main User Commuting Use Frequent Infrequent

Access to Other Vehicles by Additional Driver:

-- Owner Named Driver Company Vehicle None

Occupation:

Employment Status:

-- Employed Houseperson Director Unemployed Self Employed

Employers Business Type:

Title:

-- Miss Ms Mr Mrs Dr Captain Lady Lord

Forenames:

Surname:

Gender:

-- Male Female

Marital Status:

-- Married Single Civil Partnered Widowed Divorced

Date of Birth:

You must be 21 or over

Place of Birth:

When did they become an IOM/UK Resident:

Licence Type:

-- Provisional UK Full UK European International

Date Passed Test:

Relationship to Proposer:

-- Spouse Civil Partner Commonlaw Spouse Parent Offspring Sibling None

Use of Vehicle:

-- Main User Commuting Use Frequent Infrequent

Access to Other Vehicles by Additional Driver:

-- Owner Named Driver Company Vehicle None

Occupation:

Employment Status:

-- Employed Houseperson Director Unemployed Self Employed

Employers Business Type:

Title:

-- Miss Ms Mr Mrs Dr Captain Lady Lord

Forenames:

Surname:

Gender:

-- Male Female

Marital Status:

-- Married Single Civil Partnered Widowed Divorced

Date of Birth:

You must be 21 or over

Place of Birth:

When did they become an IOM/UK Resident:

Licence Type:

-- Provisional UK Full UK European International

Date Passed Test:

Relationship to Proposer:

-- Spouse Civil Partner Commonlaw Spouse Parent Offspring Sibling None

Use of Vehicle:

-- Main User Commuting Use Frequent Infrequent

Access to Other Vehicles by Additional Driver:

-- Owner Named Driver Company Vehicle None

Occupation:

Employment Status:

-- Employed Houseperson Director Unemployed Self Employed

Employers Business Type:

Claims Information:

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Incident Date:

Estimate Own Damage Cost:

Estimate Third Party Cost:

Personal Injury:

-- No Yes

If yes, please fill give the cost below.

Personal Injury Cost:

Was the incident under this policy:

-- No Yes

Full Incident Description:

You can provide details of the circumstances.

Claims Information:

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Incident Date:

Estimate Own Damage Cost:

Estimate Third Party Cost:

Personal Injury:

-- No Yes

If yes, please fill give the cost below.

Personal Injury Cost:

Was the incident under this policy:

-- No Yes

Full Incident Description:

You can provide details of the circumstances.

Claims Information:

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Incident Date:

Estimate Own Damage Cost:

Estimate Third Party Cost:

Personal Injury:

-- No Yes

If yes, please fill give the cost below.

Personal Injury Cost:

Was the incident under this policy:

-- No Yes

Full Incident Description:

You can provide details of the circumstances.

Claims Information:

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Incident Date:

Estimate Own Damage Cost:

Estimate Third Party Cost:

Personal Injury:

-- No Yes

If yes, please fill give the cost below.

Personal Injury Cost:

Was the incident under this policy:

-- No Yes

Full Incident Description:

You can provide details of the circumstances.

Claims Information:

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Incident Date:

Estimate Own Damage Cost:

Estimate Third Party Cost:

Personal Injury:

-- No Yes

If yes, please fill give the cost below.

Personal Injury Cost:

Was the incident under this policy:

-- No Yes

Full Incident Description:

You can provide details of the circumstances.

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Offence Code:

Offence Date:

Conviction Date:

Number of Penalty Points on Licence for Conviction:

Amount of Fine for Conviction:

Months Suspended:

Drink Driving Reading:

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

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Offence Code:

Offence Date:

Conviction Date:

Number of Penalty Points on Licence for Conviction:

Amount of Fine for Conviction:

Months Suspended:

Drink Driving Reading:

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

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Offence Code:

Offence Date:

Conviction Date:

Number of Penalty Points on Licence for Conviction:

Amount of Fine for Conviction:

Months Suspended:

Drink Driving Reading:

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

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Offence Code:

Offence Date:

Conviction Date:

Number of Penalty Points on Licence for Conviction:

Amount of Fine for Conviction:

Months Suspended:

Drink Driving Reading:

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

Which Driver:

-- Insured Driver 2 Driver 3 Driver 4

Offence Code:

Offence Date:

Conviction Date:

Number of Penalty Points on Licence for Conviction:

Amount of Fine for Conviction:

Months Suspended:

Drink Driving Reading:

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

Cover:

-- Comprehensive Third Party Fire & Theft Third Party Only

Annual Mileage:

-- Under 5,000 5,000–8,000 8,000–10,000 10,000–12,000 Over 12,000

Class of Use:

-- Social Domestic and Pleasure Social Domestic & Pleasure including Carriage of own Goods (Excluding Hire & Reward)

When did/does policy expire:

Insurer Name:

Previous Policy Number:

Number of Years Bonus:

-- 1 2 3 4 5 6 7 8 9

Is protected No Claims Discount required:

-- Yes No

You understand and agree to the information being submitted:

-- I understand and agree to the information submitted.

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

You accept our Terms of Business and Privacy Notice

-- I have read and accept the Terms of Business and Privacy Notice.

Please read our Terms of Business and Privacy Notice and Data Policy
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