Insurance and Financial Services
for the Dental Profession

To discover the benefits of insuring your car through BDA Plus, simply complete the brief details below and we will contact you with a quotation.

You

Salutation *	Please Select Mr Mrs Ms Miss Dr
Forename *
Surname *
Proposer Date of birth *
Gender *	Please Select Male Female
Address *
Postcode *
BDA Member *	Please Select Yes No
Telephone *
Email Address
Mobile
Full UK driving license *	Please Select Yes No
If no, please give details:
If yes, how many years held?	Years
Are you the main driver? *	Please Select Yes No
What prompted you to visit our website? *	Please select BDA Conference BDA News BDA News Insert Steamline dedupe The Dentist Magazine Mailing - Brand Mailing Mailing - Prospect Mailing - Membership Insert Google BDA Website PR Activities Word of mouth

Vehicle Details

Make *
Model *
CC
Transmission *	Please Select Manual Auto Paddle shift
Fuel *	Please Select Petrol Diesel LPG Hybrid
Current Mileage *
Registration Date *
Approx Purchase Date *
Vehicle Value *
Annual Mileage (personal) *	miles
Annual Mileage (business) *	miles
Where is the vehicle kept overnight? *	Please select Drive Garage Public Road Car Park Other
Is the vehicle right hand drive? *	Please select Right Left
Has the vehicle been modified? *	Please select Yes No
Is the vehicle fitted with a security device? *	Please select Yes No
If yes, please give details, eg. manufacturer device

Cover Details

Drivers *	Please select Yourself Only Yourself & Spouse Yourself & named drivers Any driver over 25
Cover Type *	Please select Comprehensive Third Party, fire & theft
Driving Use *	Please select Social, Domestic & Pleasure Social, Domestic & Please, inc Commuting Class 1 Business Use Class 2 Business Use
No Claims Bonus *	Please select 1 2 3 4 5 6 7 8 9 10 10+
Protect No Claims Bonus? *	Please select Yes No

Driving Hitory

Have you suffered any claims in the last 5 years? *	Please select Yes No
If yes, please give details of dates, incident and costs
Have you received any driving convictions in the last 5 years? *	Please select Yes No
If yes, please give details of dates, incident and costs

Additional Drivers

Additional Driver 1
Salutation	Please Select Mr Mrs Ms Miss Dr
Forename
Surname
Date of birth
Relationship to policyholder?
Occupation
Full UK driving license	Please Select Yes No
If no, please give details:
If yes, how many years held?	Years
Frequency of use?	Please Select Infrequent Moderate Frequently

Additional Driver 2
Salutation	Please Select Mr Mrs Ms Miss Dr
Forename
Surname
Date of birth
Relationship to policyholder?
Occupation
Full UK driving license	Please Select Yes No
If no, please give details:
If yes, how many years held?	Years
Frequency of use?	Please Select Infrequent Moderate Frequently

General Information

Preferred Total Excess	Please select £50 £100 £200 £250 £300
Existing Insurer *
Renewal Date *
Current Premium *

*Denotes compulsory field

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