Quotation Request Motor Breakdown - DJB R 1 2 3 4 Complaint Module Cover Details 1 Vehicle Details Make: - select - A.D. Tramontana AC Propulsion Acura AC AJS Alfa Romeo Alpine Amuza Anteros Aprilia Arash Ariel Arrinera Ascari ASL Asterio Aston Martin Audi Austin Autocars Co. B Engineering BAC Bajaj Beijing Automobile Works Benelli Bentley Bertone BMW Bollore Bolwell Brilliance / HuaChen Bristol British Leyland BRM Buggy Brooke Buddy Bufori Bugatti Buick BYD Cadillac Caparo Carbontech Carice Chang'an Changhe Chery Chevrolet Chevron Chrysler Citroen Commer Commuter Cars Connaught Covini Dacia Daewoo Daihatsu De La Chapelle De Tomaso Devon Diardi DMC Dodge Dongfeng Donkervoort Donto DS Automobiles Ducati Dynasti Electric E-Vade Eagle Effedi Egy-Tech Engineering Electric Raceabout Elfin Emgrand Englon Equus Eterniti Etox Exagon Faralli & Mazzanti FAW Ferrari Fiat Fisker Foday Force Ford Australia Ford Germany Ford Fornasari Geely Gentry Geo Gibbs Gillet Ginetta Gleagle GMC Gonow Great Wall / Changcheng Grinnall GTA Motor Gumpert Hafei Harley-Davidson Hillman Hindustan Holden Hommell Honda Hongqi Hradyesh HTT Technologies Hulme Hyosung Hyundai ICML IFR Imperia Infiniti Invicta Iran Khodro Isdera Isuzu Iveco JAC Jaguar Jeep Jensen Motors Jetcar Jonway JOSS Kaipan Kantanka Kawasaki Kiat Kia Kish Khodro Koenigsegg Korres KTM Lada Lamborghini Lambretta Lancia Land Rover Landwind Laraki LDV LeBlanc Leopard Lexmoto Lexus Li-ion Lifan Lightning Lincoln Lister Lobini Local Motors Lotec Lotus Lucra Cars Luxgen Mahindra Maruti Suzuki Maserati Mastretta Mazda McLaren Mercedes-Benz Mercury MG Micro MINI Mitsubishi Mitsuoka Morgan Mullen Mycar Nash Motors Nissan Noble Nota Opel Optimal Energy Orca Other P.G.O. Pagani Panhard Panoz Perana Perodua Peugeot Piaggio Plymouth Polarsun Pontiac Porsche Proto Proton Puritalia Qoros Qvale Radical Reliant Renault REVA Rimac Rinspeed Roding Roewe Rolls-Royce Rossin-Bertin Rossion Rover Group Rover Saab SAIC-GM-Wuling SAIPA Saker Samsung San Sbarro Scion Scomadi SEAT Shanghai Maple Shelby Singer Sin Skoda Smart Spada Vetture Sport Spyker Ssangyong Street & Racing Technology Subaru Suzuki Talbot Tanom Tata Tauro Tawon Car TD Cars Tesla Thai Rung Toyota Trident Triumph Troller Trumpchi Tushek TVR TVS UEV Ultima UMM Uri Vauxhall Vector Vencer Venturi VEPR Vespa Volkswagen Volvo W Motors Wallyscar Westfield Wheego Wiesmann Yamaha YES! Youabian Puma Zastava Automobiles Zender Cars Zenvo ZiL Model: Year of Manufacture: - select - 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Registration -Hidden- Base Rate £ - Hidden - Base Rate 2 £ -Hidden- Quoted ? -Hidden- 2nd Veh Rates -Hidden- 3rd Veh Rates -Hidden- 4th Veh Rates - Hidden - Payment Method 2 Cover Details When would you like cover to commence? 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 2019 2020 Please select the level of cover you require: Silver 3Would you like to include misfuel cover for your vehicle(s)?We'll cover you in the event of you fuelling your vehicle with an incorrect fuel type. Should this happen, one of our recovery operators shall attend and drain your vehicle of the incorrect fuel type. We shall also fuel your vehicle with £20 of the correct fuel. For just £6 per vehicle YesNo Would you like to include keycare cover for your vehicle(s)?In the event of the vehicle's keys being damaged in any way, lost or issue with key fobs or immobiliser keys, we shall recover the vehicle to the nearest garage able to effect a repair. For just £2.50 per vehicle YesNo Would you like to increase your cover to unlimited callouts?Our standard cover allows you up to 6 callouts within the duration of policy. With our unlimited callouts option this gives you ultimate peace of mind knowing that no matter how often you need us, we will always be there. For just £3.00 per vehicle YesNo 4If you have a discount code please enter it here: A 10% discount will be applied to your quotation Declaration I understand that I will not be able to make a claim under this policy for the first 48 hours from the start date of the policy as I have selected. I also agree to the terms and conditions of the membership as outlined I hereby declare the details I have submitted to be true and accurate. Also my vehicle, to the best of my knowledge, is in a good state of mechanical and electrical repair, holds a current UK M.O.T. (where applicable) and is road legal ComplaintsComplaint 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 2017 2018 2019 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 2017 2018 2019 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 2017 2018 2019 Cover Details Set + CommissionLift £ £0.00 Set + Auto Load £ £0.00 Set + Use Load @ % £0.00 Set + MPA Load @ % £0.00 Set + Radius Load @ % £0.00 Set + Ownership Load @ % £0.00 Set + Horsebox Load @ % £0.00 Set + Vehicle 2 Use Load @ % £0.00 Set + Vehicle 2 MPA Load @ % £0.00 Set + Vehicle 2 Radius Load @ % £0.00 Set + Vehicle 2 Ownership Loaf @ % £0.00 Set + Vehicle 2 Horsebox Load @ % £0.00 Set + Vehicle 2 Bongo Load @ % £0.00 Set + Vehicle 3 Use Load @ % £0.00 Set + Vehicle 3 MPA Load @ % £0.00 Set + Vehicle 3 Radius Load @ % £0.00 Set + Vehicle 3 Ownership Load @ % £0.00 Set + Vehicle 3 Horsebox Load @ % £0.00 Set + Vehicle 3 Bongo Load @ % £0.00 Set + Vehicle 4 Use Load @ % £0.00 Set + Vehicle 4 MPA Load @ % £0.00 Set + Vehicle 4 Radius @ % £0.00 Set + Vehicle 4 Ownership Load @ % £0.00 Set + Vehicle 4 Horsebox Load @ % £0.00 Set + Vehicle 4 Bongo Load @ % £0.00 Set - Multi Vehicle Discount @ % £0.00 Set - Discount £ £0.00 Set - Adjustment @ % £0.00 Set + Misfuel £ £0.00 Set + Keycare £ £0.00 Set + Excess £ £0.00 Set + Unlimited Callouts £ £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