For Insurance - Four Counties! Best for choice, best for price, best for advice

For insurance - since 1969
www.4counties.co.uk

 

Confused by the vast range of insurance companies - all promising everything, but often only interested in grabbing your money, regardless of what you need?
Use our online quote systems to check your own quote, or call and speak to one our trained advisers and let us do all the hard work for you, free and with no obligation. We know you'll be impressed

Telephone 08456 300 200

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Insurance Quote

Your Contact Details

Name:
Home Telephone:
Daytime or work Telephone:
Mobile Telephone:
E-mail (required):  

Vehicle Details

Make:
Model:  
Year of Registration:
Seating capacity
Engine Capacity: cc
Estimated Value: £ (Agreed value policies will be provided if photos are produced)
Alarm/Immobiliser details:

Driver Details

Main Driver Second Driver
Title: Title:
Forename: Forename:
Surname: Surname:
Address: Relationship:
Town:
County:
Post Code:
  Licence:   Licence:
Licence date  Licence date 
Marital status Marital status
 Birthdate:  Birthdate:
Occupation: Occupation:
Employer's Business: Employer's Business:  
Total Number of Drivers 

(if more than 2, enter details for the
                             youngest or worst!)

If this is a second vehicle, how many years No Claims Discount is there on your first vehicle?  

Accidents, claims or losses in the past 5 years 

Date / Circumstances / Cost of Claim / Was No Claims Discount affected? 
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2

Convictions in the past 5 years (but include any drink/drugs offences or other serious convictions up to 11 years ago)

Date / Offence Code / Points / Fine / Suspension period / Alcohol level (if appl)
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2

Disabilities or infirmities (these should have been notified to DVLA, Swansea)

Please Specify, with details of duration & treatment & any restrictions on driving licence
Driver 1 or 2? 1 2
Driver 1 or 2? 1 2

Policy Cover Details

Type of Cover:
No Claims Discount:
Protected No Claims Discount?: Yes No 
Low annual mileage?
Select one of these:
Type of Use:   
Date cover required: This should be within the next 30 days
Target Premium: Please state your current premium, not what you hope for! 
This will help us quote the best premium possible.
Need to add or explain something? Tell us here:
Unless you say otherwise, we will assume:
You are the registered keeper and vehicle owner
The vehicle is garaged at the above address
The vehicle is not a "personal import" and has not been modified from standard
You are a homeowner 
You do not have any criminal convictions

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