Car Insurance Application Form

Am I eligible for ManxCover car insurance?

You should be able to answer yes to the following:

All drivers are aged between 25 and 74,
all drivers have held a full IOM/UK driving licence for more than 12 months,
all drivers do not have a health condition that may affect driving,
all drivers have never had insurance refused or conditions imposed,
there are no more than 4 named drivers,
and the vehicle is standard and unmodified.

Please take a few moments to complete the form below.

If you have any questions, call us on 01624 832042.

Date Quotation Required From:

Insured Personal Info

Surname:
Sex:
Marital Status:
Title:
Forenames:
Address:
Post Code:
Property Type:
Date of Birth:
Place of Birth:
When did you become an IoM/UK resident:
Licence Type:
Date Past Test:
Contact Tel Number(s):
Occupation:
Employment Status:
Employers Business Type:

Non Rating Information

Email Address:: If you provide a contact email address we will email you confirmation when you submit this form
Target Premium Quote:
Target Insurer:
How did you hear about us:

Vehicle Details

Make:
Model:
Exact Type:
Year of Manufacture:
Engine cc:
Registration Number:
Estimated Market Value:
Date of Purchase:
Price Paid:
Body Type:
Manual or Automatic?
Number of Doors:
Number of Seats:
Left Hand Drive:
ABS Fitted:
Where kept over night:
Registered Keeper & Owner:
Access to Other Vehicles by Proposer:
Number of Vehicles in Household:

Driving Restrictions:

Additional Driver 1

Surname:
Sex:
Marital Status:
Title:
Forenames:
Date of Birth:
Place of Birth:
When did they become an IoM/UK Resident:
Licence Type:
Date Past Test:
Relationship to Proposer:
Use of Vehicle:
Access to Other Vehicles by Additional Driver:
Occupation:
Employment Status:
Employers Business Type:

Additional Driver 2

Surname:
Sex:
Marital Status:
Title:
Forenames:
Date of Birth:
Place of Birth:
When did they become an IoM/UK Resident:
Licence Type:
Date Past Test:
Relationship to Proposer:
Use of Vehicle:
Access to Other Vehicles by Additional Driver:
Occupation:
Employment Status:
Employers Business Type:

Additional Driver 3

Surname:
Sex:
Marital Status:
Title:
Forenames:
Date of Birth:
Place of Birth:
When did they become an IoM/UK Resident:
Licence Type:
Date Past Test:
Relationship to Proposer:
Use of Vehicle:
Access to Other Vehicles by Additional Driver:
Occupation:
Employment Status:
Employers Business Type:

Additional Driver 4

Surname:
Sex:
Marital Status:
Title:
Forenames:
Date of Birth:
Place of Birth:
When did they become an IoM/UK Resident:
Licence Type:
Date Past Test:
Relationship to Proposer:
Use of Vehicle:
Access to Other Vehicles by Additional Driver:
Occupation:
Employment Status:
Employers Business Type:

Has the proposer or named driver had any accidents, claims or incidents in any vehicle in the last 5 year:: If yes, please fill in the details below.

Accidents/Claims/Incident Details 1

Claims Information:
Which Driver:
Incident Date:
Estimate Own Damage Cost:
Estimate Third Party Cost:
Personal Injury:: If yes, please fill give the cost below.
Personal Injury Cost:
Was the incident under this policy:
Full Incident Description:: You can provide details of the circumstances.

Accidents/Claims/Incident Details 2

Claims Information:
Which Driver:
Incident Date:
Estimate Own Damage Cost:
Estimate Third Party Cost:
Personal Injury:: If yes, please fill give the cost below.
Personal Injury Cost:
Was the incident under this policy:
Full Incident Description:: You can provide details of the circumstances.

Accidents/Claims/Incident Details 3

Claims Information:
Which Driver:
Incident Date:
Estimate Own Damage Cost:
Estimate Third Party Cost:
Personal Injury:: If yes, please fill give the cost below.
Personal Injury Cost:
Was the incident under this policy:
Full Incident Description:: You can provide details of the circumstances.

Accidents/Claims/Incident Details 4

Claims Information:
Which Driver:
Incident Date:
Estimate Own Damage Cost:
Estimate Third Party Cost:
Personal Injury:: If yes, please fill give the cost below.
Personal Injury Cost:
Was the incident under this policy:
Full Incident Description:: You can provide details of the circumstances.

Accidents/Claims/Incident Details 5

Claims Information:
Which Driver:
Incident Date:
Estimate Own Damage Cost:
Estimate Third Party Cost:
Personal Injury:: If yes, please fill give the cost below.
Personal Injury Cost:
Was the incident under this policy:
Full Incident Description:: You can provide details of the circumstances.

Has the proposer or named driver had any motoring convictions:: If yes, please fill in the details below.

Convictions 1

Which Driver:
Offence Code:
Offence Date:
Conviction Date:
Number of Penalty Points on Licence for Conviction:
Amount of Fine for Conviction:
Months Suspended:
Drink Driving Reading:: Full details of the reading, ie. Blood, Urine.

Convictions 2

Which Driver:
Offence Code:
Offence Date:
Conviction Date:
Number of Penalty Points on Licence for Conviction:
Amount of Fine for Conviction:
Months Suspended:
Drink Driving Reading:: Full details of the reading, ie. Blood, Urine.

Convictions 3

Which Driver:
Offence Code:
Offence Date:
Conviction Date:
Number of Penalty Points on Licence for Conviction:
Amount of Fine for Conviction:
Months Suspended:
Drink Driving Reading:: Full details of the reading, ie. Blood, Urine.

Convictions 4

Which Driver:
Offence Code:
Offence Date:
Conviction Date:
Number of Penalty Points on Licence for Conviction:
Amount of Fine for Conviction:
Months Suspended:
Drink Driving Reading:: Full details of the reading, ie. Blood, Urine.

Convictions 5

Which Driver:
Offence Code:
Offence Date:
Conviction Date:
Number of Penalty Points on Licence for Conviction:
Amount of Fine for Conviction:
Months Suspended:
Drink Driving Reading:: Full details of the reading, ie. Blood, Urine.

Additional Information

Cover:
Annual Milage:
Class of Use:

No Claims Bonus:: Note: NCB can only be used on one vehicle at a time and must be less than 24 months old.

Previous Insurance

When did/does policy expire:
Insurer Name:
Previous Policy Number:
Number of Years Bonus:
Is protected No Claims Discount required:

Submit this form to us and we will get back to you as soon as we can with a quote. If you have provided your email address you will receive email confirmation. If you require any help, please call us on 01624 832042.