Apply for Limousine Insurance - Limosure Limousine Insurance

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Personal Information
First Name*
Last Name*
Street*
City*
State*
Post Code*
Phone*
Email*
Do you confirm that all nominated drivers are above the age of 25?
Please note that our insurers are unable to extend cover to drivers under the age of 25.

Your vehicle(s)

Vehicle Year	Vehicle Make	Vehicle Model	Agreed Value	Actions

There are no Vehicles.

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Nominated Drivers
Nominated Drivers*
Name of Driver Date of Birth % of Use

Please provide the following details for each driver who will use the vehicle, including yourself and any additional nominated drivers.
In the LAST FIVE (5) YEARS have any Nominated Drivers had any accidents, vehicles stolen or burnt, or any other losses involving a vehicle where an insurance claim has been made?*
- No
- Yes
List of Accidents/Claims
Driver Date Details Amount

Please list accidents/claims
In the LAST FIVE (5) YEARS have any Nominated Drivers committed any traffic offences which have resulted in a penalty being imposed/ points lost?*
- No
- Yes
Driving History (Last 5 Years): Have any Nominated Drivers had their licence suspended, good behaviour periods imposed, or other special terms imposed on their license within the last 5 years?*
- No
- Yes
Personal History (Last 5 Years): Have any of the above Drivers had any criminal conviction, bankruptcy, Insurance claim declined, or declined/cancelled insurance within the last 5 years?*
- No
- Yes
List of Offences
Please list offences
Driver Date Offence Penalty Additional Information
Comments & Notes:
Phone
This field is for validation purposes and should be left unchanged.

Name of Driver	Date of Birth	% of Use

Driver	Date	Details	Amount

Driver	Date	Offence	Penalty	Additional Information

Personal Information