Carriagehouse Insurance Equestrian Specialists
The Predictable Helping You with the Unpredictable!

RIDER AND DRIVER - PERSONAL ACCIDENT ONLINE QUOTE FORM

Please complete the following sections as applicable

If you are under 18 years old, this form must be signed by your parent, guardian or legal representative
 
Rider and Driver - Personal accident online quote form
The Policyholder details:
Your Full Name
Address
Town
County
Postcode
Relationship to the Insured Person named below: (if applicable)
Contact telephone number:
Email Address:
Occupation:
Date of birth:
If below 18 years of age: Are you in full time education?
The Insured Person details:
(If different from above)
Your Full Name
Address
Town
County
Postcode
Contact telephone number:
Email Address:
Occupation:
Date of birth:
Please indicate which of the following activities will be participated in:
Green denotes Class A - Purple denotes Class B - Red denotes Class C
Hacking/Pleasure driving Long distance Riding/Driving (under 30 miles)
Show jumping Endurance Riding/Driving (over 30 miles)
Showing Cross Country
Pony/Riding/Driving Club Meetings Local level one day events
Gymkhanas Driving trials/marathons/scurries
Western Riding Hunting
Dressage (and cones) Affiliated eventing/show jumping
Other - please state
General Questions
1. Has the proposed person held personal accident cover during the past 12 months?
If Yes, please state the insurer:
2. Have the proposed person ever had a loss that could have resulted in a claim on this policy?
If Yes, please provide further details:
3. Has any insurer declined to provide such insurance, imposed special terms or cancelled a policy?
If Yes, please provide further details:
4. Has the proposed person any physical defect or infirmity?
If Yes, please provide further details:
5. Have you (the proposer), or the insured person (if different) ever been convicted of any offence involving dishonesty, fraud, violence, criminal damage, arson or drugs or is any prosecution pending?
If Yes, please provide further details:
  

Carriagehouse Insurance Services, Spring Farm, Stratford St Mary, Colchester, Essex, CO7 6NB  Telephone 01206 337388