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We arrange insurance for all cars, including: Audi, Aston Martin, Alfa Romeo, Bently, BMW, Citroen, Daewoo, Daihatsu, Fiat, Ford, Honda, Hyundai, Jaguar, Isuzu, Land Rover, Lotus, Mazda, Mercedes Benz, MG, Mazda, Mini, Mitsubishi, Nissan, Peugeot, Porsche, Renault, Rover, Saab, Seat, Skoda, Smart, Subaru, Toyota, TVR, Vauxhall, Volkswagen, Volvo

JUKES INSURANCE BROKERS
63 Broad St., Bromsgrove, Worcestershire, UK, B61 8LL
Tel: 01527 874 092 / 575 175
Fax: 01527 575 307
Quotation Request:
Scooters / Mopeds
    privacy policy
Contact Details
Title

First-name

Surname

Address

Postcode:

Telephone

Your e-mail address


MAIN RIDER

Title

First-name

Surname

Date of Birth

(day/month/year)

Marital Status
How long have you lived in the UK?
 (years)
Are you a home owner?
 yes      no
Employment Status
Occupation
Employers Business
Part Time Occupation
Part Time Employer's Business
How many vehicles in your household?
Type of licence
If you do not have UK licence, please state country where licence was issued
How long have you held your licence?
years
Brief details of any disabilities/medical conditions
Brief details of previous accidents / claims in the past five years
  
Brief details of convictions or outstanding prosecutions
 

YOUR BIKE / SCOOTER
Make
.............
Model
.................
Engine size (cc)
cc
Year of manufacture
Approximate Market Value                      £
  
Registration Number
Approximate annual mileage
.................
.................
.................
Details of any modificaitons
...
.................
If the bike is not owned / registered in your name, please give details
Where is the bike usually kept overnight?
.................
 

OTHER

The bike / scooter will be used for Social Domestic and Pleasure (SD&P) and...
How much No-Claims- Discount do you have?
years      %
Please select the cover you require
Quotation for 12 months cover to start
(day/month/year)