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| I confirm that I have read the FloriGuard website
privacy statement
(tick box) |
| I confirm that I have read the FloriGuard Capacity and Services information
(tick box) |
| I agree to receiving marketing information from
Bridge Insurance Brokers Ltd or from selected business partners
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| CONTACT INFORMATION |
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| Your name: |
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Your telephone number: |
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| Your email: |
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Best time to call you: |
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| 1st line of your address: |
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Postcode: |
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| VEHICLE INFORMATION |
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| Make of Vehicle: |
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Model: |
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| Registration (if known): |
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Year of registration: |
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| Engine Size (CC): |
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Gross Vehicle Weight (if known): |
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| Gears: |
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Fuel Type:
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| Where is the vehicle kept overnight: |
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1st Line of address where the vehicle is kept: |
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| Postcode of where vehicle is kept: |
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| POLICY INFORMATION |
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Registered owner / Keeper of the Vehicle (if different from above): |
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Driving Restriction: |
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| Average Mileage Per Year (business): |
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Average Mileage Per Year (personal): |
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| Cover required: |
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Full UK Breakdown Cover (only £35): |
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| No claims bonus available to use on vehicle: |
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Do you wish to protect your no claims bonus: |
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| POLICYHOLDER / MAIN DRIVER |
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| Policyholder Name: |
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Salutation: |
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| Main user name (if different to above) |
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Salutation: |
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| Date of birth |
(dd/mm/yyyy) |
Marital Status: |
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| Licence Type: |
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Number of years held: |
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| Do you have use of another vehicle: |
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Is there no claims bonus available: |
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| MOTORING CONVICTIONS |
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| Have any of the drivers had any motoring convictions, disqualifications or prosecutions pending: |
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| Driver name: |
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Date of conviction:
Conviction Code:
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| Fine amount: |
£
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Points:
Length of Ban (if app.)
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| Driver name: |
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Date of conviction:
Conviction Code:
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| Fine amount: |
£
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Points:
Length of Ban (if app.)
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| Driver name: |
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Date of conviction:
Conviction Code:
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| Fine amount: |
£
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Points:
Length of Ban (if app.)
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| CLAIMS HISTORY |
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| Have you or any drivers had any accidents, losses or incidents in the last 5 years: |
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| Driver name: |
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Description:
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| Date:
Amount/cost: £
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| Driver name: |
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Description:
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| Date:
Amount/cost: £
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| Driver name: |
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Description:
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| Date:
Amount/cost: £
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| YOUR CURRENT INSURANCE |
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| Who is your current insurer? |
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| When is cover required? |
(dd/mm/yyyy) |
| What are you currenly paying? |
£ |
| Any further information: |
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IMPORTANT: In order for us to process your
quotation we also make certain assumptions to provide you with a
fast quotation. By ticking the box you confirm that you
have read and agree with the statements click
here to view
NOTE: If information provided
is incorrect or incomplete Insurers may not pay your claim.
Details you provide may be checked by Insurers against data
held elsewhere. |
Please contact us on 0845 313 9871 if you
cannot proceed any further. |
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