Request for Change

MiniWorld Insurance Services
PROTECTING YOUR PASSION

Tel: 0844 888 0770

Request for Change

CUSTOMER DETAILS

Title:

First Name:

Surname:

Postcode:

Policy Number:

Daytime Phone Number:

E-mail Address:

WHAT WOULD YOU LIKE TO CHANGE?

Please note that this is only an enquiry to request a change under your policy. No change will be effected or cover altered in any way. One of our operators will contact you shortly to discuss the change prior to any cover being altered.

Change of Address: No Yes

New Address Details

New Contact Telephone Number

Where will your vehicle be kept?

Change of Occupation: No Yes

Occupation

Business Type

Employment Status

Vehicle Use

Add Additional Driver No Yes

IF YOU WISH TO ADD MORE THAN 1 DRIVER PLEASE CONTACT THE OFFICE FOR A QUOTATION

Driver Details

Date of Birth

Status

License Details
Passed on

Occupation

Business Type

Employment Status

Does this driver require commuting?

Any Accidents/Claims in last 5 years?
No Yes

Claim 1

Claim Date (dd/mm/yyyy)

Claim Type

Total Cost

At Fault

Claim 2

Claim Date (dd/mm/yyyy)

Claim Type

Total Cost

At Fault?

Claim 3

Claim Date (dd/mm/yyyy)

Claim Type

Total Cost

At Fault

Claim 4

Claim Date (dd/mm/yyyy)

Claim Type

Total Cost

At Fault

Claim 5

Claim Date (dd/mm/yyyy)

Claim Type

Total Cost

At Fault

Any Motoring Convictions in last 5 years?
No Yes

Conviction 1

Offence Date (dd/mm/yyyy)

Conviction Code

Did this result in a ban?

Points

Fine

Banned Length

Convicted Date (dd/mm/yyyy)

Conviction 2

Offence Date (dd/mm/yyyy)

Conviction Code

Did this result in a ban?

Points

Fine

Banned Length

Convicted Date (dd/mm/yyyy)

Conviction 3

Offence Date (dd/mm/yyyy)

Conviction Code

Did this result in a ban?

Points

Fine

Banned Length

Convicted Date (dd/mm/yyyy)

Conviction 4

Offence Date (dd/mm/yyyy)

Conviction Code

Did this result in a ban?

Points

Fine

Banned Length

Convicted Date (dd/mm/yyyy)

Conviction 5

Offence Date (dd/mm/yyyy)

Conviction Code

Did this result in a ban?

Points

Fine

Banned Length

Convicted Length (dd/mm/yyyy)

Remove a Driver: No Yes

Name(s) of driver(s) to remove

Change of Vehicle: No Yes

Vehicle Details

Engine Size
cc

Year of Manufacture

Value
�

Vehicle Security Device

Is the Vehicle a Kit Car?

Is the Vehicle Imported?

Is the Vehicle Modified?
No Yes

Total Value of Mods
�

Other Change: No Yes

Please enter your request here.

Terms & Conditions

MiniWorld Insurance Services is brought to you by HIC. MiniWorld Insurance Services is a trademark of IPC Media, who acts as an introducer to us, HIC - Herts Insurance Consultants ltd - Registered No. 3735354, Registered Office, 22-26 Kings Street Kings Lynn Norfolk PE30 1HJ. HIC is incorporated in the UK and is authorised and regulated by the Financial Services Authority No 309073. We are members of the Financial Services Compensation Scheme and the Financial Ombudsman Service. HIC will arrange and administer your insurance which will be underwritten by selected insurers.