Al Hakim Auto Insurance
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+44 7787 484769
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Taxi Insurance
Home Insurance
Business Insurance
Price Searching
Contact Us
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Van Insurance
Taxi Insurance
Home Insurance
Business Insurance
Price Searching
Contact Us
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How did you hear about us
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Word of Mouth
Existing customer
Friend or Family
Email/Newsletter
Social Media
The internet search
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This information is solely for our marketing purpose
About You
Title
*
Title
Mr
Mrs
Miss
Dr (male)
Dr (female)
Frist Name
*
Last Name
*
Address (House Number, Street, City)
*
Post Code
*
Were you born in the UK
*
Were you born in the UK
Yes
No
If No, when did you last become a UK resident
*
Date of Birth
*
Marital Status
*
Marital Status
Single
Married
Civil Partner
Cohabiting
Divorced
Separated
Widowed
Employment Status
*
Employment Status
Employed
Unemployed
Self-Employed
House Person
Education
Retired
If Employed/Self Employed, What's your main occupation?
*
If Employed/Self Employed, What industry is this occupation in?
*
Any children under 16
*
Any children under 16
Yes
No
Home owner
*
Home owner
Yes
No
Contact Details
Email
*
Phone
*
Vehicle Details
Vehicle Registration
Date of purchase
*
Use of Vehicle
*
Select
Social, domestic, pleasure, commuting (SDPC)
Social, domestic and pleasure only (SDP)
SDPC and business use (proposer/spouse only)
SDPC and business use (any named driver)
SDPC and business use (proposer only)
Type of Cover
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Select
Comprehensive
Third party fire & theft
Third party only
Any no claims discount
*
Select
No NCD
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years +
Would you like to protect your NCD
*
Select
Yes
No
When would you like the policy to start
*
How do you normally pay for insurance?
*
Select
Monthly
In Full
Driving History
Type of License
*
Type of License
Full UK Manual
Full UK Automatic
Provisional UK
Full Euro EEC
Other International
License Number
Period license held for
*
Period license held for
Less than 1 Year
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
25+ Years
What date was license obtained
*
Any driver insurance declined, cancelled, voided or special terms imposed?
*
Yes
No
Do you have any non-motoring criminal convictions?
*
Yes
No
Do you have any non-motoring criminal convictions?
Additional Drivers
Would you like to add an additional driver
Yes
No
Additional Driver Details
Title
Title
Mr
Mrs
Miss
Dr (male)
Dr (female)
Frist Name
Last Name
Relationship to Proposer
Select
Spouse
Civil Partner
Common Law Partner/Cohabitee
Son/Daughter
Parent
Brother/Sister
Other Family
Employee
Employer
Business Partner
Other
Date of Birth
Marital Status
Marital Status
Single
Married
Civil Partner
Cohabiting
Divorced
Separated
Widowed
Employment Status
Employment Status
Employed
Unemployed
Self-Employed
House Person
Education
Retired
If Employed/Self Employed, What's your main occupation?
Address (House Number, Street, City)
Type of License
Type of License
Full UK Manual
Full UK Automatic
Provisional UK
Other International
Period license held for
Period license held for
Less than
1 Year1
Year2
Years3
Years4
Years5
Years6
Years7
Years8
Years9
Years10
Years11
Years12
Years13
Years14
Years15
Years16
Years17
Years18
Years19
Years20
Years21
Years22
Years23
Years24
Years25
Years25+
Were they born in the UK
Were they born in the UK
Yes
No
If less than 3 years, please advise on date obtained
If No, when did they last become a UK resident
Motor Accidents
Have you had any motor accidents (fault or non-fault) or claims (whether claim made or not) in the last 5 years
*
Yes
No
Motor Accident or Claim Details
Who was driving?
Select
Me
Another Driver
Driver Name
Type
Select
Accident
Explosion
Fire Damage
Lightning Damage
Malicious Damage
Riot Damage
Storm Damage
Theft - Accessories
Theft - Personal Effects
Theft - Sound Equipment
Theft Of Vehicle
Theft Related Damage
Windscreen Only
Date
Damage
Select
Damaged - Amount Known
No Damage
Unknown
Write-Off
Cost(£) - if known
Fault
Select
Both parties
No other vehicle involved
Other party
Our Driver
Unoccupied Vehicle
Any Injuries
Select
Yes
No
Motor Convictions
Have you had any motor convictions, fixed penalties or disqualifications in the last 5 years
*
Yes
No
Motor Conviction, Fixed Penalty or Disqualification Details
Conviction Code
Select
AC10
AC20
AC30
AC99
BA10
BA20
BA30
BA99
CD10
CD20
CD30
CD40
CD50
CD60
CD70
CD80
CD90
CD99
CU10
CU20
CU30
CU40
CU50
CU60
CU80
DD10
DD20
DD30
DD40
DD50
DD60
DD70
DD80
DD90
DR10
DR20
DR30
DR40
DR50
DR60
DR70
DR80
DR90
IN10
LC10
LC20
LC30
LC40
LC50
MS10
MS20
MS30
MS40
MS50
MS60
MS70
MS80
MS90
MS99
MW10
PC10
PC20
PC30
PL10
PL20
PL30
PL40
PL50
SP10
SP20
SP30
SP40
SP50
SP60
TS10
TS20
TS30
TS40
TS50
TS60
TS70
TT99
UT10
UT20
UT30
UT40
UT50
Date
Damage
Select
Damaged - Amount Known
No Damage
Unknown
Write-Off
Points
Select
None
1
2
3
4
5
6
7
8
9
10
11
12
Fine(£) - if any
Ban (months) - if any
Current Insurance Status
Do you currently have insurance?
Select
Yes
No
If Yes
Additional Information
Additional Comments
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Privacy Policy
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Confirmation of Understanding
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I understand that Al Hakim Auto Insurance does not make any personal recommendations as to the suitability of the policy to an individual needs or circumstances. I am using their services as technical support to help me search the web and find multiple insurance quotes.
We do not act as a broker or agent for any particular insurance company, we are here for you and only you on behalf of you. Although we cannot give you advice regarding your insurance needs, we can search the market for the best prices on your behalf as long as you provide us with accurate information and you are comfortable with your insurance needs.
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