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Telephone

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Forename

Surname

House Name/Number

Street

Town/City

County

Post Code

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Total Annual Mileage

Your Tax Rate

Your Salary

Work Hours Per Week

Date of Birth

Are you an essential user?

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Your Gender

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Have you had more than one at fault accident in the last 3 years?

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Have you accumulated more than 6 points on your driver's licence in the last 3 years?

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Is the vehicle fitted with a tracking device?

Yes No

Is the vehicle garaged?

Yes No

How many years no claims bonus?

Who will drive the vehicle?

Additional Driver 1 Name

Additional Driver 1 DOB

Additional Driver 2 Name

Additional Driver 2 DOB

Your insurance is only valid if you meet the following criteria:

You are a permanent employee and not in a probation period.
All drivers are resident in the mainland United Kingdom.
All drivers are aged 18 to 68.
Not subject to a driving ban in the last 5 years.
No more than 1 fault claim for all insured drivers in the last 3 years.
No more than 6 points accumulated on the driving licence in the last 3 years.

If you are unsure as to your eligibility for insurance on the scheme please contact tchsalsa@howdeninsurance.co.uk or call TCH Salsa at Howden Insurance on 01924 973970.

Please tick the boxes below to confirm you have read, understood and accept the terms.

It is essential that you read through the Key Information to ensure that all the details are correct and that the cover provided meets your needs.

The Policy forms the basis of the insurance contract for the cover as set out. It is therefore important that you have disclosed all material facts. Failure to disclose such facts may result in claims not being met. If you are in any doubt about whether a fact is material, you should disclose it.

Your insurance policy provided with your vehicle will be supplied by Allianz via our partner broker Howden Insurance.

I confirm that no driver has any unreported medical conditions of which the DVLA should be notified.

I confirm that the above conditions are met and that no driver has had insurance refused or special terms imposed.

I confirm that I have read the policy and that to the best of my knowledge and belief all the answers are true and no material facts have been omitted. Also I confirm that I have read and understood the Key Facts and that I agree to accept the policy subject to its terms, conditions and exceptions.

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