Van Insurance Application Form — ManxCover

Am I eligible for ManxCover van 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 3 named drivers.
The vehicle is standard and unmodified.
Vehicle will not carry any inflammable, toxic, corrosive, explosive or otherwise dangerous substances.
Vehicle will not be used for business abroad.
Vehicle will not be used at any time on any part of a commercial or military airport or airfield.
Vehicle will not be used for Hire and Reward.
Vehicle is not refrigerated, does not have a tipping unit and does not exceed 3.5 tonnes in weight.
Vehicle is a standard panel van or pickup with seating capacity for no more than 5 people.

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

Company Name:
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:
Licence Date:
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:
Number of Seats:
Gross Vehicle Weight:
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:
Licence Date:
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:
Licence Date:
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:
Licence Date:
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:
Licence Date:
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.