Please complete details of your cover request, then click the send details button to pay by credit card and we will contact you to confirm cover has been arranged. Please note there is no cover in force until we confirm

Alternatively you can ring us and we will arrange cover over the phone with you, or post to you.

Any Questions? Please contact us on 08456 300 200

How to use this form:
Step 1 - Tell us when you want cover to start
Step 2 - Tell us how you want to pay the premium
Step 3 - Tell us how much you are paying now, by credit or debit card

We will confirm receipt of the information and will subsequently e-mail confirmation of payment and confirm that cover has been arranged. Please note cover will not be in force until you receive confirmation to you that you are insured. 

If you do not receive an e-mail confirmation within 48 hours, please contact us 
(telephone 08456 300 200 or e-mail insure@4counties.co.uk) 

Step 1 - Cover date:
Please state the date you would like cover to start from: (please enter as DD/MM/YYYY, for example 01/01/2010)
Please state the type of insurance you are paying for:
(NB: Cover will not be in place until you receive an e-mail confirmation from us that your requested payment has
been received and that cover is effective. This can take up to 48 hours, please remember this if you have
requested cover to start within 48 hours. Please also allow extra time at weekends and public holidays.)
Step 2 - How do you want to pay?
Please state the reason for your payment:
Bank details For New or Renewal premiums (annual policies only)

If you are only paying a deposit now and want to pay the balance by monthly direct debit, please confirm your bank details (no other paperwork will be required):		 Sort code:
  Account number:
  Account name:
   
Bank details For New or Renewal premiums (annual policies only)

If you are only paying a deposit now and want to pay the balance by monthly direct debit, please confirm your bank details (no other paperwork will be required):		 Sort code:
  Account number:
  Account name:
   
Enter the amount you wish to pay (either the full premium or a 15% deposit)
Step 3 - How much are you paying now?  
Please deduct this amount from my credit card: Payment = £ pounds sterling only
Use this space for any comments or special instructions

Horsebox Insurance Cover Request

Contact Details
Preferred contact telephone number: Is this number your   
Alternative telephone number: Is this number your  
E-mail (required):
Vehicle Details
Make:
Model:
Registration number:
Year of Registration:
Estimated Value:£
Is vehicle fitted with a Battery Isolator or Fuel Cut-Off device?   This is a security device that many insurers require to be fitted to high-value vehicles
Gross vehicle weight:  Please state whether this in kilograms (kg), tons/tonnes(t) or hundredweight (cwt)?
Alarm/Immobiliser details:  
Mileage  
Number of Horses carried  
How many beds does the vehicle have?:   Does the vehicle have cooking facilities?   
Driving Restriction  
Describe what you will be using the horsebox for:  
Type of Cover:  
Driver Details

Main Driver Second Driver
Title:   Title:
Forename:   Forename:
Surname:   Surname:
Address:   Relationship:
       
Town/City:      
County:      
Post Code:   Post Code Where Kept (if Different):   If not kept at your home, how many other vehicles are kept at the storage location?
       
  Licence: Licence:
Licence date    (DD/MM/YYYY) Licence date  (DD/MM/YYYY)
How long have you been driving horseboxes?      
Marital status   Marital status
 Birthdate:   (DD/MM/YYYY) Birthdate: (DD/MM/YYYY)
Occupation:   Occupation:
Employer's Business:   Employer's Business:  

Have there been any Accidents, Claims or Losses in the past 5 years 
If yes please complete the following details:
(You should mention all incidents, irrespective of whether an insurance claim was made or not)
Date / Circumstances / Cost of Claim / Was No Claims Discount affected? 
Driver Main Second
Driver Main Second
Driver Main Second

Do you or other drivers had any Convictions in the past 5 years
(but include any drink/drugs offences or other serious convictions up to 11 years ago)   
If yes please complete the following details:
(Please include all fixed penalty offences)
Date / Offence Code / Points / Fine / Suspension period / Alcohol level (if appl)
Driver Main Second
Driver Main Second
Driver Main Second
Driver Main Second

Do you or any other driver have any Disabilities or infirmities (these should have been notified to DVLA, Swansea)    If yes, please complete the following details:
 
Please Specify, with details of duration & treatment & any restrictions on driving licence
Driver Main Second
Driver Main Second
 
 
Date cover required:   This should be within the next 30 days
Number of years claim-free driving
Who was your last insurer?
Need to add or explain something? Tell us here: