Proposers Name

Postal Address



Date of Birth

E-mail address

Phone Number

CC of Vehicle

Value of Vehicle



Year of Manufacture

Manufactured as a campervan?
 yes no

Purchase Date

If converted does vehicle have 1.8 meter internal height?
 yes no

Is campervan currently insured?
 yes no

Cover Required

Use of Vehicle: Holiday use and for social, domestic and pleasure purposes only

Type of License: Must have a full license

Endorsments/Convictions (Proposer or any other drivers)


Penalty Points (Proposer or any other drivers)

Details of Penalty Points

Penalty Points (Proposer or any other drivers)

Private car insurance in own/Spouse/partners name

Any claims for proposer or any named drivers within the last 5 years

Details of Claims

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