Motor Wheelchair Accessible Vehicles
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Motor Wheelchair Accessible Vehicles

Please complete the form below and a broker from our office will contact you shortly. Please note a medical certificate is required for drivers 80 years of age or over and we will also need a copy of your current Motor Vehicle certificate or your insurer's written confirmation of your No Claim rating.

Complete All Fields
  • Proposer's Full Name
  • Postal Address
  • Home Phone Number
  • Mobile Number
  • Email
  • Period of Insurance
  • Vehicle Full Description (including registration number, year, make and sum insured)
  • Main Driver's Full Name
  • Main Drivers License Number
  • Details of Motor Vehicle Claims
  • Dates of Motor Vehicle Claims
  • Have you had a traffic or criminal conviction?
    Yes
    No
  • Dates of Convictions
  • Penalty/Amount Paid
  • I declare that I have read Whitbread's Financial Services Guide, the Insurer's Product Disclosure Statement and complied with my Duty of Disclosure as per the Insurance Contracts Act 1984.
    Yes
    No
  • Security Code