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Proposer Details Proposer Title MR MISS MRS MS DR Proposer Forenames Proposer Surname Proposer E-mail Address Daytime Telephone Number Postcode where the vehicle is kept (BTXX XXX or BTX XXX) Date Of Birth Proposer gender MALE FEMALE Proposer occupation None of the Below Accountants Actor Actress Airline Pilots Amusement Arcade Staff Architects Bank Manager Bookmakers/Turf Accountants Casino/Gaming Club Staff Chemists Circus Staff Civil Servant Clergymen Dentist Diplomatic Staff Disco/Nightclub Staff Doctors (Medicine) Fairground Staff Fashion Models Film Industry Flight Personnel Foreign Embassy Staff Full-Time Teacher General Dealer Gown/Fur/Fashion Designer Gown/Fur/Fashion Proprietor Journalist Law Society Law Society/Bar Council Lecturer Member of Emergency Services Member of Police Service Motor Trader Musician Off-Shore Worker Photographic Models Press Photographer Professional Engineer Professional Sportsperson Professional Surveyor Racing/Gaming Industry Radio Industry Scrap Metal Worker Street/Market Trader Television Industry Unemployed (not inc Housewife/Student/Retired) Vets Job Desk Bound? NOYES Accomodation Type OWNER OCCUPIED PRIVATE RENTED LIVING WITH FAMILY (OWNER OCCUPIED) LIVING WITH FAMILY (PRIVATE RENTED) SHARING (OWNER OCCUPIED) SHARING (PRIVATE RENTED) OTHER How many years no claims discount does the proposer have? NONE 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS OR MORE Is a Protected Bonus required? NOYES Years FULL licence held:

Vehicle Details Make AC AIXAM ALFA ROMEO ALLARD ALVIS AMC ANT ARM SIDDELEY ARO ASIA ASTON MARTIN AUDI AUSTIN AUTO UNION BENTLEY BITTER BMW BOND BORGWARD BRISTOL BUGATTI BUICK CADILLAC CATERHAM CHEVROLET CHRYS AUS CHRYSLER CITROEN CLUB CAR COLT DACIA DAEWOO DAF DAIHATSU DAIMLER DALLAS DATSUN DE TOMASO DELOREAN DODGE ERA FACEL VEGA FAIRTHORPE FERRARI FIAT FORD FORD (AUS) FORD (USA) FSO GEM GILBERN GINETTA GOGGOMOBIL HILLMAN HINDUSTAN HOLDEN HONDA HUMBER HUMMER HYUNDAI ISO RIVOLTA ISUZU JAGUAR JEEP JENSEN JOWETT KHALEEJ KIA LADA LAMBORGHINI LANCHESTER LANCIA LANDROVER LEXUS LEXUS (USA) LIGIER LINCOLN LONSDALE LOTUS MAHINDRA MARANELLO MARCOS MARLIN MASERATI MAYBACH MAZDA MERCEDES MERCEDES-BENZ MERCURY MG MICROCAR MINI MITSUBISHI MORGAN MORRIS MOSKVICH MOSLER NAC MG NISSAN NOBLE NSU OKA OPEL PANHARD PANTHER PERODUA PEUGEOT PGO PORSCHE PORTARO PROTON RELIANT RENAULT REVA RILEY ROLLS ROYCE ROVER SAAB SAN SANTANA SAO SEAT SECMA SIMCA SINGER SKODA SMART SSANGYONG STANDARD SUBARU SUNBEAM SUZUKI TALBOT TATA TD THINK TOYOTA TRIUMPH TVR VALIANT VANDEN PLAS VAUXHALL VENTURI VEXEL VOLGA VOLKSWAGEN VOLVO WARTBURG WOLSELEY YUGO/ZASTAVA Model  (eg fiesta, golf)    Year Of Make 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 Fuel type PETROL DIESEL Manual/Automatic MANUAL AUTOMATIC Engine Size --- Please Select --- 1000 OR LESS 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 5000 6000 7000 8000 9000 OR MORE Value of vehicle (£) Parking location (Overnight) CARPORT GARAGE DRIVEWAY PUBLIC ROAD Class Of Use SDP&C CLASS 1 CLASS 2 CLASS 3    Annual Mileage

Additional Drivers D.O.B. Gender Relationship To Proposer Occupation Date Passed Test   MALE FEMALE   BUSINESS PARTNER CHILD COMMON-LAW SPOUSE DIRECTOR FAMILY LODGER PARENT PROPOSER'S EMPLOYEE PROPOSER'S EMPLOYER SPOUSE UNRELATED   None of the Below Accountants Actor Actress Airline Pilots Amusement Arcade Staff Architects Bank Manager Bookmakers/Turf Accountants Casino/Gaming Club Staff Chemists Circus Staff Civil Servant Clergymen Dentist Diplomatic Staff Disco/Nightclub Staff Doctors (Medicine) Fairground Staff Fashion Models Film Industry Flight Personnel Foreign Embassy Staff Full-Time Teacher General Dealer Gown/Fur/Fashion Designer Gown/Fur/Fashion Proprietor Journalist Law Society Law Society/Bar Council Lecturer Member of Emergency Services Member of Police Service Motor Trader Musician Off-Shore Worker Photographic Models Press Photographer Professional Engineer Professional Sportsperson Professional Surveyor Racing/Gaming Industry Radio Industry Scrap Metal Worker Street/Market Trader Television Industry Unemployed (not inc Housewife/Student/Retired) Vets   MALE FEMALE   BUSINESS PARTNER CHILD COMMON-LAW SPOUSE DIRECTOR FAMILY LODGER PARENT PROPOSER'S EMPLOYEE PROPOSER'S EMPLOYER SPOUSE UNRELATED   None of the Below Accountants Actor Actress Airline Pilots Amusement Arcade Staff Architects Bank Manager Bookmakers/Turf Accountants Casino/Gaming Club Staff Chemists Circus Staff Civil Servant Clergymen Dentist Diplomatic Staff Disco/Nightclub Staff Doctors (Medicine) Fairground Staff Fashion Models Film Industry Flight Personnel Foreign Embassy Staff Full-Time Teacher General Dealer Gown/Fur/Fashion Designer Gown/Fur/Fashion Proprietor Journalist Law Society Law Society/Bar Council Lecturer Member of Emergency Services Member of Police Service Motor Trader Musician Off-Shore Worker Photographic Models Press Photographer Professional Engineer Professional Sportsperson Professional Surveyor Racing/Gaming Industry Radio Industry Scrap Metal Worker Street/Market Trader Television Industry Unemployed (not inc Housewife/Student/Retired) Vets   MALE FEMALE   BUSINESS PARTNER CHILD COMMON-LAW SPOUSE DIRECTOR FAMILY LODGER PARENT PROPOSER'S EMPLOYEE PROPOSER'S EMPLOYER SPOUSE UNRELATED   None of the Below Accountants Actor Actress Airline Pilots Amusement Arcade Staff Architects Bank Manager Bookmakers/Turf Accountants Casino/Gaming Club Staff Chemists Circus Staff Civil Servant Clergymen Dentist Diplomatic Staff Disco/Nightclub Staff Doctors (Medicine) Fairground Staff Fashion Models Film Industry Flight Personnel Foreign Embassy Staff Full-Time Teacher General Dealer Gown/Fur/Fashion Designer Gown/Fur/Fashion Proprietor Journalist Law Society Law Society/Bar Council Lecturer Member of Emergency Services Member of Police Service Motor Trader Musician Off-Shore Worker Photographic Models Press Photographer Professional Engineer Professional Sportsperson Professional Surveyor Racing/Gaming Industry Radio Industry Scrap Metal Worker Street/Market Trader Television Industry Unemployed (not inc Housewife/Student/Retired) Vets

How many vehicles do you (and your spouse) own or have use of (including the vehicle to be covered)? 1 2 3 Do ALL drivers on this policy aged under 25 own and insure their own vehicle? NOYES Have any drivers to be insured had more than one non-fault, full recovered, settled claim during the last 3 years? NOYES Is there other than 1 speeding conviction in total for all drivers within the last 5 years? NOYES

Have you previously had use of a company car? NOYES Did you have sole use of the company car? NOYES For how many did you drive the company car claim free? NONE 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS OR MORE Date company car use ended?

How many years have you been a named driver on a UK PRIVATE CAR policy? NONE 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS OR MORE Is this policy claim free for the last 3 years? YESNO Have you held a FULL driving licence for the total period of time for which equivalent bonus has been claimed? NOYES If the NCD has not been earned on a UK policy in the Proposer's own name, please provide further details.

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