Step One
Proposer Contact Details
Surname*
First Name*
Title*	Dr Miss Mr Mrs Ms
House Number/Name
Postcode*
Contact Telephone*
Email Address*
Gender*	Male Female
Date of Birth*	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   01 02 03 04 05 06 07 08 09 10 11 12   1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989
Occupation*	Clerical Company Director Customer Services Drivers H M Forces Housewife/Husband Manual Motor Trade Other Professional Proprietor Public Services Retired Skilled Student Unemployed
Business Description*
Marital Status*	Married Single Divorced Widowed Common Law
Disabilities* If yes please give details	Yes No
Are you existing client of Keith Michaels Plc?*	Yes No
Where did you hear about us?*
Driving Information
Type of Vehicle*	Car Van Motorcycle
Type of License Held*
Type of Cover*	Comprehensive Third Party, Fire and Theft Third Party
Test Passed/License Obtained*	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   01 02 03 04 05 06 07 08 09 10 11 12   1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Are You a Home Owner?*	Yes No
Any claims?* ...in the last five years, regardless of blame.	Yes No
Any driving convictions?*...in the last 5 years (if banned in the last 10 years)	Yes No
When do you want cover to start?*	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   01 02 03 04 05 06 07 08 09 10 11 12   2008 2009 2010 2011 2012
Vehicle Registration
Estimated vehicle value (£)*
Where will the vehicle be kept overnight?*	Street Driveway Garage
Additional Drivers*	Yes No
No Claims Bonus*	0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9+ Years
Protect NCB?* If NCB 4+ years	Yes No
Number of Vehicles in Household
Keith Michaels PLC is authorised and regulated by the Financial Services Authority. Registered no. 306600