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Proposal Form

Please only use the mouse to move between boxes, only press the
enter key when you are satisfied that all boxes are complete.

* - denotes required fields

Email (required)
*
Address Details
Name
*
Address 1
*
Address 2
Town/City
*
County
*
Postcode
*
Contact Details
Landline
*
Mobile
Personal Details
Date of Birth
*
Occupation
*
Current Penalty Points ?
*
Number of Pending Penalty Points ?
*
Nature of Pending Motoring Conviction

Any Medical Conditions Affecting You ?
Please check the appropriate answer.
No Yes

Nature of Any Medical Conditions
Policy Applied For
Platinum
238.14
Gold
191.84
Flashguard+
78.75
Flashguard
55.13

I apply for a policy subject to the terms and conditions detailed in this website, which I have read, and I agree that this application shall form the basis of the contract for the insurance and that if anything be untruly stated or so withheld as to influence the decision of the insurer either now or afterwards the contract or agreement shall be voidable at the option of the insurer. After payment, any refunds will only be given at the discretion of the Company Management.

I agree.
I disagree.

Credit Card Details
Exact Name On Card
*
Card Number
*
Valid From
Expiry Date
*
Security Number (Last 3 on signature strip)
*
Issue Number (If Switch)
   
Comments:

Please review your details and alter any that are incorrect, when you are happy that you have completed all relevant information please click on the "Submit My Proposal Form" below to send the proposal form.

 

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