Form

INSURANCE QUOTE FORM:
POLE POSITION RACING
MOTORCYCLE SHOP / RACING TEAM

Unit 5, 100 The Highway London E1W 2BX,
Tel: 0044(0)20 7702 9381, Fax: 0044(0)20 7998 0586

Company Registration Number: 6683127
1. Full Name*
First Name Last Name
2. E-mail*

3. Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

4. Phone Number*
- Area Code Phone Number
5. Birth Date*
Day Month Year
6. Profession*
7. Are you a resident in the UK?*

Yes No
8. If not born in the UK when did you arrive to the UK*
9. Are you a home owner, otherwise, please state whether you share or live with parents*
10. What is your marital status*

Married Single Other
11. Medical conditions if any*
12. Have you ever cancelled insurance before? If yes, state why*
13. What type of driving licence: full / provsional (British/EU, EEC/ other etc)*
full/ provisional, please state
14. CBT/UK Provisional-When has been done?*
15. How long have you had this driving license for*
16. Do you have a car you would like to insure*

Yes No
17.Have you had any other quote and how much for*
18. When does your current insurance expires/ or expired?*
/ Month / Day Year
19. What type of insurance do you require ?*
20. What is your attempted use?*
21. Have you had an accident during last five years,*

No Yes
22. If yes; provide the details where, when and short info how did it happen.*
23. Did you get your compensation and how much did you receive*
24. Have you had any motoring convictions during the last five years (for example: speeding, drink driving)*

Yes No
25. If yes, provide details*
26. Have you received bans/ disqualifications from driving during last 11 years*

Yes No
27. How many years NO CLAIM BONUS*
Details of a motorcycle to be insured: All fields are compulsory
28. Make*
29. Model*
30. Registration Number*
31. Capacity of the engine in CC /CM3*
32. Year of production*
33. Estimated mileage per year*
31. Are you the only registered keeper*

Yes No
32. Is there an ABS fitted in the vehicle?*
33. What type of security is currently n the vehicle (alarm, tracker, chain etc)*
34. Detailed description of your security system (example: Datatool S4 C1 Red, Tracker Monitor, Thatcham Category 3 security chain)*
35. Where is the motorcycle kept (a garage, off street parking etc)*
35a. If off-street parked - what are the conditions?*
36. If a vehicle kept in a garage –what is the garage made of (brick, wood etc)*
37. Is the motorcycle with a trailer?*

No Yes
38. Turbo?*

No Yes
39. Panniers?*
40. What is the estimated market value of the vehicle?*
Enter the message as it's shown*
Request to Pole Position Racing Ltd: Please provide me with an insurance quote using my details listed above. Information given to you is to my best knowledge true.

All information is confidential
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First Name Last Name
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INSURANCE QUOTE FORM:

Request to Pole Position Racing Ltd: Please provide me with an insurance quote using my details listed above. Information given to you is to my best knowledge true.