Contact Name:
Company Name:
Type of Goods Carried:
Quotation Required By:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
January
February
March
April
May
June
July
August
September
October
November
December
Email Address:
Company Address:
Current Insurer
Number of vehicles
1
2
3
4
5
6
Your Telephone Number:
Company Post Code:
Target Premium
GVW
Year of make
NCB Years
Does NCB originate
from car or CV?
Please indicate basis
against each vehicle
1.
Please Select
Car
Cv
Please Select
1 named
2 named
3 named
4 named
Any 25yrs+
2.
Please Select
Car
Cv
Please Select
1 named
2 named
3 named
4 named
Any 25yrs+
3.
Please Select
Car
Cv
Please Select
1 named
2 named
3 named
4 named
Any 25yrs+
4.
Please Select
Car
Cv
Please Select
1 named
2 named
3 named
4 named
Any 25yrs+
5.
Please Select
Car
Cv
Please Select
1 named
2 named
3 named
4 named
Any 25yrs+
6.
Please Select
Car
Cv
Please Select
1 named
2 named
3 named
4 named
Any 25yrs+
Do you want us to quote for Protected
NCB as an option on those vehicles
with 5 years minimum NCB?
yes
no
Do you require Goods in Transit
cover?
yes
no
Is a higher Transit limit than £25,000 per vehicle required?
yes
no
If so what limit?
Any other material facts/information including any claim details and convictions in the last 3 years:
FM Green Wholesale is authorised and regulated by the Financial Services Authority.
