Quotation Request Form
Fields marked with an * are required If yes, please provide the insurer name and renewal date Please answer these questions...Address of equipment (if different to above)
Tell us about you.....
Full Name
Date of Birth
Call Sign
Email
Phone Number
Occupation
Address Line 1
Address Line 2
City
Post Code
Address where your radio equipment is kept
Address Line 1
Address Line 2
City
Post Code
Is your radio shack a room inside your house, or an external building (e.g. a shed)
Please describe the type of locks on your radio shack doors and windows
What is the total current new replacement value of your equipment?
What equipment value do you want insured whilst away from your home in the UK?
What value of equipment do you want insured while abroad?
What value of equipment do you want to insure that is permanently installed in a vehicle?
Tell us about your insurance history...
Have you had any claims or losses, whether insured or not, within the last 5 years?
If yes, please provide details
Are you currently insured?
Insurer name
Renewal date
Tell us about your club...
Are you enquiring for a club, Society or organisation?
Club Name (if enquiring for a club, Society or organisation)
Position in club, Society or organisation
Do you have any convictions, criminal offences or prosecutions pending other than motor offences?
Have you ever been declared bankrupt or insolvent or the subject of bankruptcy proceedings?
Have you ever had a proposal for insurance refused or declined or ever had an insurance policy cancelled, renewal refused or had special terms imposed other than where the insurer ceased trading or no longer supports the product?
Any additional information