Insurance Quotation Request Form
About You
*
Title
Mr
Mrs
Dr
Miss
Ms
*
First Name
*
Surname
*
Street Address
*
Postcode
Contact Telephone
*
Email Address
*
Date of Birth(dd/mm/yyyy)
Sex
Male
Female
*
Occupation
*
Business Type
*
Status
Employed
Unemployed
Self Employed
Retired
Student
Household Duties
Disability
Company Director
Are you a member of a caravan club?
No
Yes
How many years caravan no claims bonus available?
0
1
2
3
4
5+
Caravan Details
Is the caravan a tourer?
Yes
No
Is the caravan single or twin axle?
Single
Twin
*
Make
*
Model
Is the caravan imported?
No
Yes
*
Date of Manufacture(yyyy)
Date of Purchase(dd/mm/yyyy)
Is the caravan used for business?
No
Yes
Is the caravan used as a permanent residence?
No
Yes
*
Risk Street Address
*
Risk Postcode
Security and Safety
*
Mule
No
Yes
*
Tyreon Bands
No
Yes
*
Factory Fitted Alarm
No
Yes
*
Hitch Post
No
Yes
*
Active Tracker
No
Yes
*
Datatag
No
Yes
Storage
*
CaSSOA Storage
None
All Year Round
Winter Storage
Cover Details
*
Value of Caravan and Fittings £
(includes awnings and gas bottles etc.)
*
Personal Possessions £
(max £3000 or 200 of caravan value)
*
Date cover required for
What's the best quote you've had elsewhere?
Is the Property:
Free from Flood?
Yes
No
Within One Mile of a River/ a Quarry/ the Sea?
No
Yes
Let for Hire and Reward?
No
Yes
Contacting You
To process your quote we may need to share your personal data within the Adrian Flux Insurance Services group and its trusted agents, however:
We would like to contact you from time to time by post, telephone, e-mail, or other electronic means with news, offers, services and promotions that are relevant and beneficial to you.
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