Quotation Request

Claim Fulfillment - CoverMy (Fortegra)

Client Details

Policy Information

Additional Drivers

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Sale Information

Complaint Module

Cover Details

Name

-- Mr Mrs Miss Ms Dr Prof. Capt. Lord Lady Major Rev. Master Exec(s) of Mx

Business Name

Mobile Telephone

-Hidden- Base Rate

£

- Hidden - Base Rate 2

£

- Hidden - Base Rate 3

£

- Hidden - Base Rate 4

£

-Hidden- Quoted ?

Policy Information

Current term

Policy number

Excess Payable

0 30

Cover Type

Vehicle Personal

Level of cover

Local Local and Home National National and Home European - Select -

Number of vehicles covered

1 2 3 4 - Select -

Inception Date

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 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2025 2026

Membership duration (days)

Wording issued at the POS

Additional Drivers

Additional Driver 1

Additional Driver 2

Additional Driver 3

Total number of people covered under this policy:

Your First Vehicle

Type of Vehicle

- select - CampervanCarCourierMopedMotor trade 3.5tMotor trade 7.5tMotorcycleMotorhomeRVTaxiVan

Select the make of your vehicle

- select - A.D. TramontanaACAC PropulsionAcuraAJSAlfa RomeoAlpineAmuzaAnterosApriliaArashArielArrineraAscariASLAsterioAston MartinAudiAustinAutocars Co.B EngineeringBACBajajBeijing Automobile WorksBenelliBentleyBertoneBMWBolloreBolwellBrilliance / HuaChenBristolBritish LeylandBRM BuggyBrookeBSABuddyBuforiBugattiBuickBYDCadillacCaparoCarbontechCariceCaterhamChang'anChangheCheryChevroletChevronChryslerCitroenCommerCommuter CarsConnaughtCoviniCupraDaciaDaewooDaihatsuDatsunDe La ChapelleDe TomasoDevonDiardiDMCDodgeDongfengDonkervoortDontoDS AutomobilesDucatiDynasti ElectricE-VadeEagleEffediEgy-Tech EngineeringElectric RaceaboutElfinEmgrandEnglonEquusEternitiEtoxExagonFaralli & MazzantiFAWFerrariFiatFiskerFodayForceFordFord AustraliaFord GermanyFornasariGeelyGeoGibbsGilletGinettaGleagleGMCGonowGreat Wall / ChangchengGrinnallGTA MotorGumpertGWMHafeiHanwayHarley-DavidsonHillmanHindustanHoldenHommellHondaHongqiHradyeshHTT TechnologiesHulmeHumberHusqvarnaHyosungHyundaiICMLIFRImperiaInfinitiInvictaIran KhodroIsderaIsuzuIvecoJACJaguarJeepJensen MotorsJetcarJonwayJOSSKaipanKantankaKawasakiKeewayKiaKiatKish KhodroKoenigseggKorresKTMLadaLamborghiniLambrettaLanciaLand RoverLandwindLarakiLDVLeBlancLeopardLexmotoLexusLi-ionLifanLightningLincolnListerLobiniLocal MotorsLotecLotusLucra CarsLuxgenMahindraMarlinMaruti SuzukiMaseratiMastrettaMazdaMcLarenMercedes-BenzMercuryMGMicroMicrocarMINIMitsubishiMitsuokaMKMorganMullenMycarNash MotorsNissanNobleNotaOpelOptimal EnergyOrcaOtherP.G.O.PaganiPanhardPanozPeranaPeroduaPeugeotPiaggioPlymouthPolarsunPontiacPorscheProtoProtonPuritaliaQorosQvaleRadicalReliantRenaultREVARimacRinspeedRodingRoeweRolls-RoyceRossin-BertinRossionRoverRover GroupRoyal EnfieldSaabSAIC-GM-WulingSAIPASakerSamsungSanSbarroScionScomadiSEATShanghai MapleShelbySinSingerSkodaSmartSpada Vetture SportSpykerSsangyongStreet & Racing TechnologySubaruSunbeamSuzukiSymTalbotTanomTataTauroTawon CarTD CarsTeslaThai RungToyotaTridentTriumphTrollerTrumpchiTushekTVRTVSUEVUltimaUMMUriVauxhallVectorVencerVenturiVEPRVespaVolkswagenVolvoW MotorsWallyscarWestfieldWheegoWiesmannYamahaYES!Youabian PumaZastava AutomobilesZender CarsZenvoZiL

Vehicle model

Year of manufacture

- select - 01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798991001011899190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Vehicle registration

Did they purchase P&L via email invitation?

YesNo

Your Second Vehicle

Type of Vehicle

- select - CampervanCarCourierMopedMotor trade 3.5tMotor trade 7.5tMotorcycleMotorhomeRVTaxiVan

Select the make of your vehicle

- select - A.D. TramontanaACAC PropulsionAcuraAJSAlfa RomeoAlpineAmuzaAnterosApriliaArashArielArrineraAscariASLAsterioAston MartinAudiAustinAutocars Co.B EngineeringBACBajajBeijing Automobile WorksBenelliBentleyBertoneBMWBolloreBolwellBrilliance / HuaChenBristolBritish LeylandBRM BuggyBrookeBSABuddyBuforiBugattiBuickBYDCadillacCaparoCarbontechCariceCaterhamChang'anChangheCheryChevroletChevronChryslerCitroenCommerCommuter CarsConnaughtCoviniCupraDaciaDaewooDaihatsuDatsunDe La ChapelleDe TomasoDevonDiardiDMCDodgeDongfengDonkervoortDontoDS AutomobilesDucatiDynasti ElectricE-VadeEagleEffediEgy-Tech EngineeringElectric RaceaboutElfinEmgrandEnglonEquusEternitiEtoxExagonFaralli & MazzantiFAWFerrariFiatFiskerFodayForceFordFord AustraliaFord GermanyFornasariGeelyGeoGibbsGilletGinettaGleagleGMCGonowGreat Wall / ChangchengGrinnallGTA MotorGumpertGWMHafeiHanwayHarley-DavidsonHillmanHindustanHoldenHommellHondaHongqiHradyeshHTT TechnologiesHulmeHumberHusqvarnaHyosungHyundaiICMLIFRImperiaInfinitiInvictaIran KhodroIsderaIsuzuIvecoJACJaguarJeepJensen MotorsJetcarJonwayJOSSKaipanKantankaKawasakiKeewayKiaKiatKish KhodroKoenigseggKorresKTMLadaLamborghiniLambrettaLanciaLand RoverLandwindLarakiLDVLeBlancLeopardLexmotoLexusLi-ionLifanLightningLincolnListerLobiniLocal MotorsLotecLotusLucra CarsLuxgenMahindraMarlinMaruti SuzukiMaseratiMastrettaMazdaMcLarenMercedes-BenzMercuryMGMicroMicrocarMINIMitsubishiMitsuokaMKMorganMullenMycarNash MotorsNissanNobleNotaOpelOptimal EnergyOrcaOtherP.G.O.PaganiPanhardPanozPeranaPeroduaPeugeotPiaggioPlymouthPolarsunPontiacPorscheProtoProtonPuritaliaQorosQvaleRadicalReliantRenaultREVARimacRinspeedRodingRoeweRolls-RoyceRossin-BertinRossionRoverRover GroupRoyal EnfieldSaabSAIC-GM-WulingSAIPASakerSamsungSanSbarroScionScomadiSEATShanghai MapleShelbySinSingerSkodaSmartSpada Vetture SportSpykerSsangyongStreet & Racing TechnologySubaruSunbeamSuzukiSymTalbotTanomTataTauroTawon CarTD CarsTeslaThai RungToyotaTridentTriumphTrollerTrumpchiTushekTVRTVSUEVUltimaUMMUriVauxhallVectorVencerVenturiVEPRVespaVolkswagenVolvoW MotorsWallyscarWestfieldWheegoWiesmannYamahaYES!Youabian PumaZastava AutomobilesZender CarsZenvoZiL

Vehicle model

Year of manufacture

- select - 01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798991001011899190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Vehicle registration

-Hidden- Quoted?

Did they purchase P&L via email invitation?

YesNo

Your Third Vehicle

Type of Vehicle

- select - CampervanCarCourierMopedMotor trade 3.5tMotor trade 7.5tMotorcycleMotorhomeRVTaxiVan

Select the make of your vehicle

- select - A.D. TramontanaACAC PropulsionAcuraAJSAlfa RomeoAlpineAmuzaAnterosApriliaArashArielArrineraAscariASLAsterioAston MartinAudiAustinAutocars Co.B EngineeringBACBajajBeijing Automobile WorksBenelliBentleyBertoneBMWBolloreBolwellBrilliance / HuaChenBristolBritish LeylandBRM BuggyBrookeBSABuddyBuforiBugattiBuickBYDCadillacCaparoCarbontechCariceCaterhamChang'anChangheCheryChevroletChevronChryslerCitroenCommerCommuter CarsConnaughtCoviniCupraDaciaDaewooDaihatsuDatsunDe La ChapelleDe TomasoDevonDiardiDMCDodgeDongfengDonkervoortDontoDS AutomobilesDucatiDynasti ElectricE-VadeEagleEffediEgy-Tech EngineeringElectric RaceaboutElfinEmgrandEnglonEquusEternitiEtoxExagonFaralli & MazzantiFAWFerrariFiatFiskerFodayForceFordFord AustraliaFord GermanyFornasariGeelyGeoGibbsGilletGinettaGleagleGMCGonowGreat Wall / ChangchengGrinnallGTA MotorGumpertGWMHafeiHanwayHarley-DavidsonHillmanHindustanHoldenHommellHondaHongqiHradyeshHTT TechnologiesHulmeHumberHusqvarnaHyosungHyundaiICMLIFRImperiaInfinitiInvictaIran KhodroIsderaIsuzuIvecoJACJaguarJeepJensen MotorsJetcarJonwayJOSSKaipanKantankaKawasakiKeewayKiaKiatKish KhodroKoenigseggKorresKTMLadaLamborghiniLambrettaLanciaLand RoverLandwindLarakiLDVLeBlancLeopardLexmotoLexusLi-ionLifanLightningLincolnListerLobiniLocal MotorsLotecLotusLucra CarsLuxgenMahindraMarlinMaruti SuzukiMaseratiMastrettaMazdaMcLarenMercedes-BenzMercuryMGMicroMicrocarMINIMitsubishiMitsuokaMKMorganMullenMycarNash MotorsNissanNobleNotaOpelOptimal EnergyOrcaOtherP.G.O.PaganiPanhardPanozPeranaPeroduaPeugeotPiaggioPlymouthPolarsunPontiacPorscheProtoProtonPuritaliaQorosQvaleRadicalReliantRenaultREVARimacRinspeedRodingRoeweRolls-RoyceRossin-BertinRossionRoverRover GroupRoyal EnfieldSaabSAIC-GM-WulingSAIPASakerSamsungSanSbarroScionScomadiSEATShanghai MapleShelbySinSingerSkodaSmartSpada Vetture SportSpykerSsangyongStreet & Racing TechnologySubaruSunbeamSuzukiSymTalbotTanomTataTauroTawon CarTD CarsTeslaThai RungToyotaTridentTriumphTrollerTrumpchiTushekTVRTVSUEVUltimaUMMUriVauxhallVectorVencerVenturiVEPRVespaVolkswagenVolvoW MotorsWallyscarWestfieldWheegoWiesmannYamahaYES!Youabian PumaZastava AutomobilesZender CarsZenvoZiL

Vehicle model

Year of manufacture

- select - 01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798991001011899190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Vehicle registration

-Hidden- Quoted?

Did they purchase P&L via email invitation?

YesNo

Your Fourth Vehicle

Type of Vehicle

- select - CampervanCarCourierMopedMotor trade 3.5tMotor trade 7.5tMotorcycleMotorhomeRVTaxiVan

Select the make of your vehicle

- select - A.D. TramontanaACAC PropulsionAcuraAJSAlfa RomeoAlpineAmuzaAnterosApriliaArashArielArrineraAscariASLAsterioAston MartinAudiAustinAutocars Co.B EngineeringBACBajajBeijing Automobile WorksBenelliBentleyBertoneBMWBolloreBolwellBrilliance / HuaChenBristolBritish LeylandBRM BuggyBrookeBSABuddyBuforiBugattiBuickBYDCadillacCaparoCarbontechCariceCaterhamChang'anChangheCheryChevroletChevronChryslerCitroenCommerCommuter CarsConnaughtCoviniCupraDaciaDaewooDaihatsuDatsunDe La ChapelleDe TomasoDevonDiardiDMCDodgeDongfengDonkervoortDontoDS AutomobilesDucatiDynasti ElectricE-VadeEagleEffediEgy-Tech EngineeringElectric RaceaboutElfinEmgrandEnglonEquusEternitiEtoxExagonFaralli & MazzantiFAWFerrariFiatFiskerFodayForceFordFord AustraliaFord GermanyFornasariGeelyGeoGibbsGilletGinettaGleagleGMCGonowGreat Wall / ChangchengGrinnallGTA MotorGumpertGWMHafeiHanwayHarley-DavidsonHillmanHindustanHoldenHommellHondaHongqiHradyeshHTT TechnologiesHulmeHumberHusqvarnaHyosungHyundaiICMLIFRImperiaInfinitiInvictaIran KhodroIsderaIsuzuIvecoJACJaguarJeepJensen MotorsJetcarJonwayJOSSKaipanKantankaKawasakiKeewayKiaKiatKish KhodroKoenigseggKorresKTMLadaLamborghiniLambrettaLanciaLand RoverLandwindLarakiLDVLeBlancLeopardLexmotoLexusLi-ionLifanLightningLincolnListerLobiniLocal MotorsLotecLotusLucra CarsLuxgenMahindraMarlinMaruti SuzukiMaseratiMastrettaMazdaMcLarenMercedes-BenzMercuryMGMicroMicrocarMINIMitsubishiMitsuokaMKMorganMullenMycarNash MotorsNissanNobleNotaOpelOptimal EnergyOrcaOtherP.G.O.PaganiPanhardPanozPeranaPeroduaPeugeotPiaggioPlymouthPolarsunPontiacPorscheProtoProtonPuritaliaQorosQvaleRadicalReliantRenaultREVARimacRinspeedRodingRoeweRolls-RoyceRossin-BertinRossionRoverRover GroupRoyal EnfieldSaabSAIC-GM-WulingSAIPASakerSamsungSanSbarroScionScomadiSEATShanghai MapleShelbySinSingerSkodaSmartSpada Vetture SportSpykerSsangyongStreet & Racing TechnologySubaruSunbeamSuzukiSymTalbotTanomTataTauroTawon CarTD CarsTeslaThai RungToyotaTridentTriumphTrollerTrumpchiTushekTVRTVSUEVUltimaUMMUriVauxhallVectorVencerVenturiVEPRVespaVolkswagenVolvoW MotorsWallyscarWestfieldWheegoWiesmannYamahaYES!Youabian PumaZastava AutomobilesZender CarsZenvoZiL

Vehicle model

Year of manufacture

- select - 01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798991001011899190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Vehicle registration

-Hidden- Quoted?

Did they purchase P&L via email invitation?

YesNo

Sale Information

Third party tracking ID

Cancellation date

Complaints

Complaint Log

• 
• 
• 

• Date of Incident

  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 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2023 2024 2025
• Date of Receipt

  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 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2023 2024 2025
• Complaint Method
• Eligible Complaint?

  Yes No Pending
• Referred to FOS?

  Yes No Pending
• Category of Complaint
• Description of Complaint
• Status
• Financial Redress Offered (£)

  £
• Accepted?

  Yes No Pending
• Closed Date

  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 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2023 2024 2025

Cover Details

Set + Auto Load			£			£0.00
Set Product Fee			£			£0.00

Total Premium (Net)						£0.00
+ VAT			@		%	£0.00
+ Policy Fee			£			£0.00
Total Premium						£0.00
Total Commission						£0.00
(Due From Broker)						£0.00