Car Insurance Online Quote Form

Policy Assist – Car Insurance Quote

Policy Assist - Car Insurance Quote

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About You

What's your title?*

Mrs

Miss

What's your first name?*

What's your last name?*

What's your email address?*

What's your mobile number?*

What's your date of birth?*

Have you been a UK resident since birth?*

Yes

When did you become permanently resident in the UK?*

What's your marital status?*

What's your full-time employment status?*

What's your occupation (e.g. Teacher or Bank Clerk)*

What industry do you work in (e.g. Banking or Education)?*

Do you have any part-time or second jobs?*

Yes

What is your part-time or second occupation (e.g. Teacher or Bank Clerk)*

What industry do you work in (e.g. Banking or Education)?*

Hidden

What is your postcode*

What is your postcode

Your Address

Hidden

Address 2*

Do you own this property?*

Yes

How long have you lived at this address?*

About Your Car

Tell us your vehicle's registration number*

Hidden

Vehicle registration number*

Hidden

Vehicle Manufacturer*

Hidden

Vehicle Model*

Hidden

Engine Size*

Hidden

Year Of Manufacture*

When did you buy this vehicle?*

What's the current the value of your vehicle?*

Are you (the policyholder) the legal owner of the vehicle?*

Yes

Who is the legal owner of the vehicle?*

Are you (the policyholder) the registered keeper of the vehicle? (i.e. the person whose name appears on the V5C log book)?*

Yes

Who is the registered keeper of the vehicle?*

Has the vehicle been modified from the manufacturer's standard specification?*

Yes

Please select the type of modification*

Do you want to add another modification?*

Yes

Please select the type of modification*

Do you want to add another modification?*

Yes

Please select the type of modification*

Do you want to add another modification?*

Yes

Please select the type of modification*

What is the car used for?*

Social Only

Social & Commuting

Business Use

How many miles will the car be driven in the next year?*

Where is the car normally parked overnight?*

On The Road

On The Drive

Garaged

Other

Please tell us where the car is parked overnight?*

About Your Driving History

What type of driving licence do you hold?*

UK Full

Automatic Only

EU Licence

UK Provisional

When did you pass your driving test?*

When did you get your provisional licence?*

Do you have any DVLA-reportable medical conditions or disabilities?*

Yes

Does the DVLA know about the medical condition or disability?*

Have you been involved in any motoring accidents, incidents or claims (regardless of fault) or suffered any type of loss in the last 5 years?*

Yes

Claim 1: What was the date of the claim / incident?*

Claim 1: What type of claim / incident was it?*

Claim 1: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 1: Please give us details of the claim / incident?*

Claim 1: Was a claim made against your insurance policy?*

Yes

Claim 1: Did the claim / incident affect your No Claims Discount?*

Yes

Do you want to add a 2nd claim / incident?*

Yes

Claim 2: What was the date of the claim / incident?*

Claim 2: What type of claim / incident was it?*

Claim 2: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 2: Please give us details of the claim / incident?*

Claim 2: Was a claim made against your insurance policy?*

Yes

Claim 2: Did the claim / incident affect your No Claims Discount?*

Yes

Do you want to add a 3rd claim / incident?*

Yes

Claim 3: What was the date of the claim / incident?*

Claim 3: What type of claim / incident was it?*

Claim 3: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 3: Please give us details of the claim / incident?*

Claim 3: Was a claim made against your insurance policy?*

Yes

Claim 3: Did the claim / incident affect your No Claims Discount?*

Yes

Do you want to add a 4th claim / incident?*

Yes

Claim 4: What was the date of the claim / incident?*

Claim 4: What type of claim / incident was it?*

Claim 4: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 4: Please give us details of the claim / incident?*

Claim 4: Was a claim made against your insurance policy?*

Yes

Claim 4: Did the claim / incident affect your No Claims Discount?*

Yes

Have you received any driving related convictions, licence endorsements, fixed penalties or been disqualifications (banned) from driving in the past 5 years or still have pending action involving motoring offences?*

Yes

Offence 1: What date were you convicted of this offence?*

Offence 1: What offence code was placed on your licence?*

Offence 1: How many penalty points did you receive for this offence?*

Offence 1: Were you banned / disqualified from driving?*

Yes

Offence 1: How long were you banned / disqualified for?*

Do you want to add a 2nd motoring conviction / offence?*

Yes

Offence 2: What date were you convicted of this offence?*

Offence 2: What offence code was placed on your licence?*

Offence 2: How many penalty points did you receive for this offence?*

Offence 2: Were you banned / disqualified from driving?*

Yes

Offence 2: How long were you banned / disqualified for?*

Do you want to add a 3rd motoring conviction / offence?*

Yes

Offence 3: What date were you convicted of this offence?*

Offence 3: What offence code was placed on your licence?*

Offence 3: How many penalty points did you receive for this offence?*

Offence 3: Were you banned / disqualified from driving?*

Yes

Offence 3: How long were you banned / disqualified for?*

Do you want to add a 4th motoring conviction / offence?*

Yes

Offence 4: What date were you convicted of this offence?*

Offence 4: What offence code was placed on your licence?*

Offence 4: How many penalty points did you receive for this offence?*

Offence 4: Were you banned / disqualified from driving?*

Yes

Offence 4: How long were you banned / disqualified for?*

Do you want to add a 5th motoring conviction / offence?*

Yes

Offence 5: What date were you convicted of this offence?*

Offence 5: What offence code was placed on your licence?*

Offence 5: How many penalty points did you receive for this offence?*

Offence 5: Were you banned / disqualified from driving?*

Yes

Offence 5: How long were you banned / disqualified for?*

Do you have any unspent criminal (non-motoring) convictions?*

Yes

About Your Policy

What cover would you like?*

Comprehensive

Third Party, Fire & Theft

Third Party Only

What date would you like cover to start?*

Today

Tomorrow

Choose A Start Date

Tell us the date would you like cover to start?*

How many years No Claims Discount (NCD) do you have?*

Would you like to protect your No Claims Discount?*

Yes

How would you like to pay for your car insurance?*

Single Annual Payment

Monthly Instalments

Have you or any additional drivers ever had an insurance policy cancelled or declared void by an insurance company?*

Yes

Are you sure? Whilst we can quote for most people, Policy Assist are a specialist insurance broker primarily for policyholders with previously cancelled or voided insurance policies

When was your policy cancelled / declared void?*

Please select the name of the insurance company that cancelled / declared your policy void?*

If you know it, please enter the name of the insurance company that cancelled / declared your policy void?*

Why did the insurer cancel / declare your policy void?*

Please tell us the reason the insurance company cancelled / declared your policy void?*

Do you want to add another driver on your policy?*

Yes

About Your Additional Driver

What's their title?*

Mrs

Miss

What's their first name?*

What's their surname?*

What's their date of birth?*

What is this driver's relationship to you?*

What's their marital status?*

Have they been a UK resident since birth?*

Yes

When did they become a permanent UK resident?*

What's their full-time employment status?*

What's their occupation (e.g. Teacher or Bank Clerk)?*

What industry do they work in (e.g. Banking or Education)?*

Do they have a second or part-time job?*

Yes

What's their second or part-time job?*

What industry is this in?*

About Their Driving History

What type of driving licence do they hold?*

UK Full

Automatic Only

EU Licence

UK Provisional

When did they pass their driving test?*

When did they get their licence?*

Do they have any DVLA-reportable medical conditions or disabilities?*

Yes

Does the DVLA know about the medical condition or disability?*

Does this driver have their own vehicle?*

Yes

Has this driver been involved in any motoring accidents, incidents or claims (regardless of fault) or suffered any type of loss in the last 5 years?*

Yes

Claim 1: What was the date of the claim / incident?*

Claim 1: What type of claim / incident was it?*

Claim 1: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 1: Please give us details of the claim / incident?*

Claim 1: Was a claim made against your named driver's insurance policy?*

Yes

Claim 1: Did the claim / incident affect their No Claims Discount?*

Yes

Do you want to add a 2nd claim / incident for this driver?*

Yes

Claim 2: What was the date of the claim / incident?*

Claim 2: What type of claim / incident was it?*

Claim 2: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 2: Please give us details of the claim / incident?*

Claim 2: Was a claim made against your named driver's insurance policy?*

Yes

Claim 2: Did the claim / incident affect their No Claims Discount?*

Yes

Do you want to add a 3rd claim / incident for this driver?*

Yes

Claim 3: What was the date of the claim / incident?*

Claim 3: What type of claim / incident was it?*

Claim 3: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 3: Please give us details of the claim / incident?*

Claim 3: Was a claim made against your named driver's insurance policy?*

Yes

Claim 3: Did the claim / incident affect their No Claims Discount?*

Yes

Do you want to add a 4th claim / incident for this driver?*

Yes

Claim 4: What was the date of the claim / incident?*

Claim 4: What type of claim / incident was it?*

Claim 4: Who was 'at fault' for this accident?*

Our Driver

The Other Driver

Both Drivers

Claim 4: Please give us details of the claim / incident?*

Claim 4: Was a claim made against your named driver's insurance policy?*

Yes

Claim 4: Did the claim / incident affect their No Claims Discount?*

Yes

Has this driver received any driving related convictions, licence endorsements, fixed penalties or been disqualifications (banned) from driving in the past 5 years or still have pending action involving motoring offences?*

Yes

Offence 1: What date were they convicted of this offence?*

Offence 1: What offence code was placed on their licence?*

Offence 1: How many penalty points did they receive for this offence?*

Offence 1: Were they banned / disqualified from driving?*

Yes

Offence 1: How long were they banned / disqualified for?*

Do you want to add a 2nd motoring conviction / offence for this driver?*

Yes

Offence 2: What date were they convicted of this offence?*

Offence 2: What offence code was placed on their licence?*

Offence 2: How many penalty points did they receive for this offence?*

Does this driver have any unspent criminal (non-motoring) convictions?*

Yes

Prefer To Call Us?

You can call us for a quote on:



(0203) 004 8585

Our Opening Hours

Monday – Friday 9am – 5.30pm
Saturday 9am – 1pm
Sunday Closed

Prefer To Call Us?

You can call us for a quote on:



(0203) 004 8585

Our Opening Hours

Monday – Friday 9am – 5.30pm
Saturday 9am – 1pm
Sunday Closed