It is important that you answer all questions with great care and that your answers are full, accurate
and truthful. This requirement applies throughout the life of the contract and not just at inception. A
failure to do this could lead to the policy being voided and claims not being paid. If you’re in any
doubts then it’s best to disclose the information and I can let you know if it’s likely to be deemed
material.
Any personal information that you provide to us will be used in accordance with our Privacy Policy
and for purposes of providing our services; Please click
HERE for a copy of our Privacy Policy.
Please note any quotation can take at least 24 hours to be received once submitted any information missing may delay obtaining a quotation.
Start Date of Cover
Cover Type
Use Required
Is the Policy Holder to be in a company name or private individual:
Name of Policy Holder:
(If Business) Nature of Business:
(If Business) Trading As:
(If Business) How long have you been in business?
(If Business) If you have ever traded in another name, please give details:
Date of Birth of proposer or Primary Contact:
Full Postal Address
Post Code
Email
Contact Telephone
Are you a member of the British Association of Shooting and Conservation (BASC)?
Employment Status:
Occupation:
Date Main Driver passed their driving test:
Type of (UK or EU) full or provisional licence (Class 1/Class 2 or Standard):
Have you ever had an insurance policy cancelled/ voided/refused/ declined or any special terms imposed? If yes please provide details:
Registration/ Chassis Number:
Make/ Model:
Cubic Capacity/Engine Size:
Year of Manufacture:
Value:
Gross Vehicle Weight:
Date of Purchase
Seats:
Number of vehicles they have access to? Do they own them?
Where is the vehicle kept overnight and postcode:
Expected Annual Private Mileage:
Expected Annual Business Mileage:
Vehicle Keeper:
Vehicle Owner:
Any changes from manufacturers' standard specification?
Any Security Devices, other than manufacturer standard equipment?
Main Driver
In the last 5 years have you been convicted of any motoring offence (including fixed penalties), been disqualified from driving or have any prosecutions pending?
Have you been convicted or charged (but not tried) of any non-motoring offence?
Have you had any accidents/claims/losses (whether to blame or not) in connection with any motor vehicle during the last 5 years?
Name of Previous Insurer:
Expiry Date:
If there are any additional drivers under 25 years of age or that has any claims or convictions in the last 5 years please continue below.
Name of Driver
Date of Birth
Occupation
Type of (UK or EU) full or provisional licence
Date named driver passed test:
Have you ever had an insurance policy cancelled/ voided/refused/ declined or any special terms imposed?
In the last 5 years have you been convicted of any motoring offence (including fixed penalties), been disqualified from driving or have any prosecutions pending?
Have you been convicted or charged (but not tried) of any non-motoring offence?
Have you had any accidents/claims/losses (whether to blame or not) in connection with any motor vehicle during the last 5 years?
Details of Additional Driver No.1
Additional Driver No.1
Date of Birth
Occupation
Type of (UK or EU) full or provisional licence
Date named driver passed test:
Have they ever had an insurance policy cancelled/ voided/refused/ declined or any special terms imposed?
In the last 5 years have they been convicted of any motoring offence (including fixed penalties), been disqualified from driving or have any prosecutions pending?
Have they been convicted or charged (but not tried) of any non-motoring offence?
Have they had any accidents/claims/losses (whether to blame or not) in connection with any motor vehicle during the last 5 years?
Disclaimer
No Claims Bonus is not considered with the agricultural scheme policy with us, therefore we advise keeping your proof of No Claims Bonus document from your insurer. The insurer will only provide a statement letter to confirm any claims within the policy year.
Data Protection Notice
Please read this notice carefully as it contains important information about the details you will have given us. It is a condition of this insurance that you read and accept the terms of this data protection notice. You should show this notice to anyone covered by this insurance. We will process the details you have provided in line with Data Protection Act 1998 and other laws which may apply. Your information may also be processed outside of the European area. In all instances we make sure that your information has enough protection. So that we can assess the terms of an insurance contract, or deal with any claims that may arise, we may need to share information which is classed as 'sensitive' under the Data Protection Act 1998. We may pass this information to other organisations that we have carefully chosen as well as other companies within our group. We share information with other insurers, certain government organisations and other authorised for the purpose of insurance underwriting, preventing or detecting fraud, managing claims and managing complaints. If you have any questions please contact the Company Secretary at ERS, 52 - 54 Leadenhall Street, London, EC3A 2BJ. By proceeding with this application you signify your consent to such information being processed in this way.
Important Notes
1. WARNING: If you provide false or incorrect information or withhold information, your policy can be cancelled or declared void. We may also refuse to pay a claim. You should keep a complete record of all information supplied to the underwriters for the purpose of entering into this contract of insurance (including copies of all letters).
2. At your request a copy of this completed form will be supplied to you, provided the request is made within a period of three months after its completion.
3. Underwriters liability does not operate until acceptance has been notified or a Cover Note delivered to the insured. If the proposal should disclose any special features the underwriters may quote special terms and they reserve the right to decline a proposal.
4. Details of full policy terms will be supplied on request.
Information about your insurance policy will be added to the Motor Insurance Database (MID) which is managed by the Motor Insurers' Bureau (MIB). Certain government or authorised organisations including the police, the DVLA, the DVLNI, the Insurance Fraud Bureau and other organisations allowed by law may use the MID and the information stored on it for the purposes including Continuous Insurance Enforcement (you can get information about this from the Department of Transport), electronic vehicle licensing, law enforcement for the purposes of preventing, detecting, catching and prosecuting offenders and providing government services or oher services aimed at reducing the level of uninsured driving. If you are involved in a road-traffic accident (either in the UK, the EEA or certain other territories), insurers or the MIB (or both) may search the MID to gather relevent information. Anyone making a claim for a road-traffic accident (including their appointed representatives and citizens of other countries) may also gather relevant information which is held on the MID. It is vital that the MID holds your correct registration number. If it is ot shown correctly on the MID, you are at risk of having your vehicle seized by the police. You can check that your correct registration number details are shown on the MID at www.askmid.com.
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