Jukes Insurance: Car Insurance / Motor Insurance Quotation for 3 drivers-- we also arrange house insurance quotes and business insurance quotesJukes Insurance: Car Insurance / Motor Insurance Quotation for 2 drivers-- we also arrange house insurance quotes and business insurance quotes

car insurance quotes, home insurance quotes and business insurance quotes at Jukes Insurance Brokers

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:
Car Insurance for 3 drivers

Contact Details
Title
First-name
Surname
Address
Postcode:
Telephone
Your e-mail address

MAIN DRIVER


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 a full 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

1st ADDITIONAL DRIVER

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 a full 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
Please state your relationship to the Main driver
Do you own your own vehicle?		Yes No

2nd ADDITIONAL DRIVER

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 a full 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
Please state your relationship to the Main driver
Do you own your own vehicle?		Yes No

YOUR VEHICLE

Make	.............
Model	.................
Model type (eg. GT)
Type of body	.................
Engine size (cc)	cc Automatic Manual
Engine size (cc)	cc Automatic Manual
Year of manufacture
Fuel Type
Number of seats
Number of doors
Approximate Market Value £
Registration Number
Approximate annual mileage	................. ................. .................


If the vehicle has been modified or tuned please give details	... .................
	... .................
If the vehicle is not owned / registered in your name, please give details
	.................
Where is the vehicle usually kept overnight?	.................

OTHER

The vehicle will be used for Social Domestic and Pleasure (SD&P) and...
How much No-Claims-Discount do you have?	years %
No Claim Bonus Protection	No Yes
Please select the cover you require	s
Quotation for 12 months based on cover starting:	(day/month/year)
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