Quotation Request Form

Tell us about you..... (if your enquiry is for a club, please contact us for further information)

Full Name

Date of Birth

Email

Phone Number

Occupation

Address Line 1

Address Line 2

City

Post Code

Address where your radio equipment is kept

Is your radio shack

At your correspondence address Another location

If equipment is kept at another location, please state full address below

Is your radio shack inside your home or in an external building (eg shed)

Room within house External building

Please describe the type of locks on your radio shack doors and windows

What is the total current new replacement value of your equipment?

Brief description of your radio equipment including masts, towers and antennas

Do you take equipment away from your home/shack and wish to insure it anywhere in the UK? If YES, please advise what sum insured is required?

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?

Yes No

If yes, please provide details

Are you currently insured?

Yes No Previously insured but no current policy

If yes, please provide the insurer name and renewal date

Insurer name

Renewal date

General questions

Has any insurer or Underwriter declined to issue or renew a policy or imposed special terms?

Yes No

If yes, please provide details

If yes, please provide full details

Have you ever been convicted of (or charged with but not yet tried for) any offence other than a driving offence?

Yes No

If yes, please provide full details

Have you ever been declared bankrupt or the subject of proceedings or made any arrangement with creditors either in a personal capacity or in connection with any company, business, or firm with which you have been involved?

Yes No

If yes, please provide full details

Address of equipment (if different to above)

Tell us about you..... (if your enquiry is for a club, please contact us for further information)

Full Name

Date of Birth

Email

Phone Number

Occupation

Address Line 1

Address Line 2

City

Post Code

Address where your radio equipment is kept

Is your radio shack

If equipment is kept at another location, please state full address below

Is your radio shack inside your home or in an external building (eg 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?

Brief description of your radio equipment including masts, towers and antennas

Do you take equipment away from your home/shack and wish to insure it anywhere in the UK? If YES, please advise what sum insured is required?

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

General questions

Has any insurer or Underwriter declined to issue or renew a policy or imposed special terms?

If yes, please provide details

Have you ever been convicted of (or charged with but not yet tried for) any offence other than a driving offence?

If yes, please provide full details

Have you ever been declared bankrupt or the subject of proceedings or made any arrangement with creditors either in a personal capacity or in connection with any company, business, or firm with which you have been involved?

If yes, please provide full details