pro-indemnity.co.uk Fleet Insurance Form Please note that you will need to fax or e-mail your current Claims Experience Document to us. You may also e-mail or fax your schedule of vehicles to us. You may e-mail to chris@pro-indemnity.co.uk or Fax to 029 2071 2919 1. Your Name:  Company Trading Title:  Type of Company: Sole TraderPartnershipLimited Company- 2. Address of your premises:  Post Code:            Telephone Number:  E-mail address:  Website address: 3. Description of Business (Occupation & Nature of all Business engaged in) :   4. Date Established: 5. Have any of the vehicles shown been altered in any way including electronically (e.g. engine or body modifications, special or non-standard equipment, non-standard wheels, or are any of them Left Hand Drive)?  Yes No 6. Has any vehicle audio/telecommunication equipment exceeding a value of £500?  Yes No 7. Has any vehicle been fitted with any security or tracking devices?  Yes No If you replied "yes" to 6,7 or 8, please give details:   8. Are all vehicles owned by you and registered in your name?  Yes No 9. Trailer cover - if cover is required for trailers whilst attached to or detached from the insured vehicles give details of number owned, makes, serial numbers and values. 10. USES   a) Will any vehicle be used for haulage purposes outside the United Kingdom?  Yes No b) Will any vehicle be used in Northern Ireland or Eire?  Yes No c) Will any vehicle be used 'airside' in any airfield or aerodrome?  Yes No d) Will any vehicle carry toxic, explosive, corrosive or inflammable goods?  Yes No e) Will any vehicle be used to carry passengers for private or public hire?  Yes No f) Will any vehicle be hired from a rank or stand, have radio communication or cruise for fares?  Yes No If you replied "yes" to a to f, please give details   11. Drivers   a) Do you or any person who may drive have defective vision or hearing (not corrected by glasses or hearing aid), any physical, mental, alcoholic or nervous disorder, or heart, diabetic or epileptic condition or other complaint, had blackouts or fits, or regularly take any prescribed medication?  YES NO If "yes", please give details including names of persons, nature of complaints, years stabilised if appropriate and details of medication. Also confirm that DVLA have been informed and advise whether your/their driving license is restricted as a result. b) Have you or has any person who drive: (i) had any motoring convictions in the last 5 years or are there any prosecutions pending or police enquiries outstanding (including fixed penalty offences)? Parking offences or a single speeding offence may be ignored.  YES NO (ii) had any criminal convictions (or been charged with a criminal offence but not yet tried)?    YES NO If YES give names of persons, offences, dates, penalties and points c) Have you or any person who may drive ever been disqualified from driving?  YES NO If YES give names of persons, offences, dates, penalties and periods of disqualification d) Do you examine the driving licences of all new employees for validity and motoring convictions?  YES NO e) Do you examine the driving licence of all employees annually to check they are valid and whether there are motoring Convictions?  YES NO f) If so, do you undertake to advise us of all motoring convictions and any restriction which may be imposed by the Authorities?  YES NO 12. INSURANCE HISTORY    a) State name of previous /present insurer showing branch, policy number and renewal date.  b) Has any company or underwriter at any time in respect of motor insurance declined to insure you, cancelled your policy, refused to renew, required increased premium or special terms?  YES NO  c) Have there been any accidents, thefts or losses (whether covered by insurance or not and regardless of blame) during the past 3 years in connection with any vehicle owned or driven by or in the charge of you or any other person who to your knowledge may drive?  YES NO  If you replied "yes" to b or c, please give details Please note that you will need to fax or e-mail your current Claims Experience Document to us. You may also e-mail or fax your schedule of vehicles to us. You may e-mail to chris@pro-indemnity.co.uk or Fax to 029 2071 2919 14. Vehicle Schedule - Please list below details of all vehicles to be insured, or alternatively, you may e-mail or fax your schedule of vehicles to us. If you need to list more than 10 vehicles, extra forms are available by clicking here Please indicate the total number of vehicles you wish to list : Make and Model Cubic / Carrying Weight (CCW) Registration Number (RegNo) Type of body and number of seats Gross Vehicle Weight (GVW) Value Cover required Year of manufacture (YoM) Class of use CCW RegNo 1 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 2 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 3 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 4 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 5 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 6 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 7 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 8 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 9 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- CCW RegNo 10 GVW Value ComprehensiveThird party Fire & TheftThird party onlyFire & Theft (laid up cover)- YoM Carriage of own goods for hire/rewardCarriage of goods for hire/rewardPrivate hirePublic hire- If you need to list more than 10 vehicles, extra forms are available by clicking here Please supply me with an estimate within 105 working days. Done   Please note that you will need to fax or e-mail your current Claims Experience Document to us. You may also e-mail or fax your schedule of vehicles to us. You may e-mail to chris@pro-indemnity.co.uk or Fax to 029 2071 2919 Please check your details, and when you are happy that all is correct, tick 'Done' and click the Submit button above...