01623 650750

Opening Hours 9am-5pm Monday-Friday

01623 663105

Opening Hours 9am-5pm Monday-Friday

01623 663101

Opening Hours 9am-5pm Monday-Friday

claims@aips.co.uk 01623 663110

Opening Hours 9am-5pm Monday-Friday

Car Insurance Form

privatecarinsurance

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Step 1 -Proposer

 Male Female
 Yes No
 Yes No
 AA RAC Green Flag Ltd Britannia Other

Step 2 - Car

Only cars registered in the UK are acceptable
*This question is asked for underwriting purposes only- all claims will be settled on a market value basis.
 Private Garage Driveway Road Car Port Car Park Other
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no
 yes no

Step 3 -Drivers

Give details of all persons who to your knowledge may drive including yourself and spouse. (If you have chosen our Solutions Plus policy the maximum number of additional drivers is two.)
Driver 1

Driver 2

Driver 3

Driver 4

Step 4 -History

Within the past five years, have you or any other person who may drive:
 Yes No
 Yes No
 Yes No
If you have ticked any of the above boxes please complete the following:
1

2

3

In respect of any person who may drive, has any inurer...:
 Yes No
 Yes No
 Yes No
If you ticked yes on the above complete the following details.
1

2

3

Step 5 -Use

In addition to social, domestic and pleasure (which permits travelling to and from work), will the car be used:
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No

Step 6 Cover and no claims discount

 Comprehensive Third Party fire and theft Third Party only
 £100 £150 £200 £250 £350
 Yourself only Yourself and spouse Yourself and named drivers (not available for Solutions Plus) Yourself and one named driver Yourself and two named drivers Any driver excluding drivers under 25 (not available for Solutions Plus)
 Yes No
 Yes No


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