FARM MOTOR FLEET REQUESTED BY CCIB 66 Derby Road, Longridge, - PDF document

C o u n t r y & C o m m e r c i a l I n s u r a n c e B r o k e r s L t d 66 Derby Road Longridge PRESTON PR3 3FE TEL: (01772) 780600 FAX: (01772) 780655 E-mail: rural@ccibltd.net FARM MOTOR FLEET REQUESTED BY CCIB 66 Derby Road, Longridge, Preston, PR3 3FE Date: Due Date: From: Deadline: Full Name of Proposer : Address: Post Code: Description of All Occupations: General Questions to be completed in every case Yes No Do you own any motor vehicles other than those declared? …. …. Have you ever traded under any other name? …. …. Has any vehicle been modified from the manufacturers standard spec? …. …. Will goods of an explosive or dangerous nature be carried at any time? …. …. Will any vehicle be kept at any address other than that shown above? …. …. Are any vehicles not registered in your name? …. …. Do you require driving to be restricted for any of the vehicles? …. …. Will any driver under the age of 25 be the main user of any vehicle? …. …. Will any vehicle be used for any purpose other than social domestic & Pleasure or farm/estate use? …. …. Will any goods carrying vehicle be used for:- i. Journeys in excess of 100-mile radius? …. …. ii. Carriage of goods for hire/reward? …. …. Will any agricultural vehicle be used for:- i. Tree Felling or haulage? …. …. ii. Agricultural Contracting? …. …. Page 1 of 3 Country & Commercial Insurance Brokers Ltd Tel: 01772 780600 Fax: 01772 780655 Email:rural@ccibltd.net CCIB LTD RURAL SOLUTIONS – FARM FLEET QUOTE REQUEST FORM

Schedule of Vehicles Schedule of Private Cars to be Insured Make & Year of Cubic Registration NCB Years Value Cover Model Make Capacity Number Protected Yes/No Schedule of Goods Carrying Vehicles to be Insured Gross Year of Registration No Claims Make & Vehicle Value Cover Make Number Bonus Model Weight Schedule of Agricultural Vehicles including combines, balers and trailers (trailers over £15000 need to be disclosed) to be Insured Year of Registration No Claims Make & Model Value Cover Make Number Bonus Page 2 of 3 Country & Commercial Insurance Brokers Ltd Tel: 01772 780600 Fax: 01772 780655 Email:rural@ccibltd.net CCIB LTD RURAL SOLUTIONS – FARM FLEET QUOTE REQUEST FORM

Drivers Details:- Date test passed Age/DOB Occupation Type of Licence Full Name Drivers History:- Have you or any person who may drive including those declared above:- Yes No a) Been refused Motor Insurance or had a motor policy cancelled, or ever had special terms imposed? …. …. b) Suffered from diabetes, epilepsy, heart condition, defective vision or hearing, loss of limb, or any other physical, mental or alcoholic condition? …. …. c) Within the last five years been convicted of any motoring offence, or have any prosecution pending? …. …. d) Been disqualified from driving or had a licence suspended or revoked? …. …. e) Had any accident, claims or losses during the last three years whether to blame or not? …. …. Name Date Circumstances Total costs-AD,TP&PI Any Other Information: Target Premium: Current Insurer: Page 3 of 3 Country & Commercial Insurance Brokers Ltd Tel: 01772 780600 Fax: 01772 780655 Email:rural@ccibltd.net CCIB LTD RURAL SOLUTIONS – FARM FLEET QUOTE REQUEST FORM