Lifesure Insurance Group

Call Us On 01480 402 460

Insurance Quote Application

Please complete your details below and we will get back to you as soon as we can with a quotation.

* Indicates Compulsory Field

Your Details
First Name: *
Surname: *
Sex: *
Date Of Birth: *
Occupation: *
Address: *
Postcode: *
Email: *
Home Telephone Number: *
Work Telephone Number:  
Mobile Telephone Number: *
When Would You Like
To Be Contacted?
Driving History
How long have you held a full UK licence? *
No Claims Bonus: *
Has the proposer received any convictions? *
If Yes, please give details, including conviction codes, dates and penalties:
Has the proposer ever made a claim? *
If Yes, please give details, including details, dates and costs:
Vehicle Details
Registration Number: *
Make: *
Model: *
Year Of Manufacture: *
Engine Capacity: *
Value Of Vehicle: *
How long have you owned a motor vehicle? *
Does the proposer have access to any other vehicles? *
Where is the vehicle stored at night? *
Left Hand Drive? *
Modifications? *
If Yes, please give details of the modifications made to the vehicle:
Security Fitted? *
Cover Details
Date Cover To Commence: *
Type Of Cover Required: *
What Do You Use The Vehicle For? *
Drivers: *
Excess Required: *
Terms & Conditions: *

The above questions aim to reduce the amount of information you need to give us to obtain a quotation. If the following statements are true, please click confirm box at the bottom of this page to proceed with your car quotation. If not, please call us on 01480 402 460 so our experienced insurance staff can try to assist you. Our business hours are 8.00am to 5:30pm Monday to Friday and 8:00am to11:45 am on Saturdays.

  • There are no more than four drivers to be covered besides yourself.
  • All drivers hold a current UK driving licence.
  • Neither you nor any of the other drivers have been medically advised not to drive.
  • You and all the other drivers are between 25 and 75 years of age (some vehicles from 21 years of age).
  • You and all the other drivers are resident in Great Britain.
  • The car is kept at your home address overnight.
  • You are the registered owner and keeper of the car.
  • Neither you nor any of the other drivers have had insurance refused in the past.
  • The car will not be used for hire or reward, or for any purpose in connection with the motor trade.
  • In the event of a claim, your information will be shared with other parties.
  • All modifications to the vehicle have been disclosed above.
  • Neither you nor anyone else who will drive the vehicle have been disqualified from driving.
  • Neither you nor anyone who will drive the vehicle has received a criminal conviction or is awaiting trial for the same.
I confirm that I have read and
understood the above terms & conditions.
Additional Details:
Additional Details:
Promotional Code:

Lifesure Group Limited (Incorporating Motorcaravan Insurance Agency Ltd) is a company authorised and regulated by the Financial Services Authority, Registration No:305038.

Copyright © Lifesure Insurance Group 2014