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Vehicle Value
Body Type
Saloon
Hatchback
Coupe
Estate
SUV
MPV
Convertible
Panel Van
Box Van
Other Van
Other Style
Number of Seats
1
2
3
4
5
6
7
8
9+
Registered Keeper
Proposer
Spouse
Parent
Common Law Partner
Civil Partner
Lease Company - Private
Lease Company - Company
Company Car
Society or club
Other
Transmission Type
Manual
Automatic
Other
Vehicle Owner
Proposer
Spouse
Parent
Common Law Partner
Civil Partner
Lease Company - Private
Lease Company - Company
Company Car
Society or club
Other
What do you use your Vehicle for?
Social, Domestic and Pleasure including travel to and from a permanent place of work
Business use by you
Business use by you and spouse/civil partner
Business use by spouse/civil partner
Business use by all drivers
Commercial travelling
Is this a Company Vehicle?
No
Yes
Security Features
Manufacturer fitted Alarm and/or immobiliser
Tracker system or similar
No Security Device
Night time parking
On a driveway at home
In a locked garage
On the road at home
In a residential car park
In a secure car park
In a carport
In a forces base car park
In an unsecure car park
In an unlocked garage
In a work car park
On the road away from home
In a railway car park
Postcode where Vehicle is normally kept overnight
Total Annual Mileage
Up to 1000
Up to 2000
Up to 3000
Up to 4000
Up to 5000
Up to 6000
Up to 7000
Up to 8000
Up to 9000
Up to 10000
Up to 11000
Up to 12000
Up to 13000
Up to 14000
Up to 15000
Up to 16000
Up to 17000
Up to 18000
Up to 19000
Up to 20000
Up to 21000
Up to 22000
Up to 23000
Up to 24000
Up to 25000
Up to 26000
Up to 27000
Up to 28000
Up to 29000
Up to 30000
Up to 31000
Up to 32000
Up to 33000
Up to 34000
Up to 35000
Up to 36000
Up to 37000
Up to 38000
Up to 39000
Up to 40000
Up to 41000
Up to 42000
Up to 43000
Up to 44000
Up to 45000
Up to 46000
Up to 47000
Up to 48000
Up to 49000
Up to 50000
More than 50000
Is the specified Vehicle currently impounded by the Police?
No
Yes
Gross Weight of Van
0 - 1.5 tonnes
1.6 - 2.0 tonnes
2.1 - 2.5 tonnes
2.6 - 3.0 tonnes
3.1 - 3.5 tonnes
Over 3.5 tonnes
Will the Van carry hazardous goods?
No
Yes
Has the Vehicle been modified in any way from that of the manufacturer's standard specification?
No
Yes
Has the Van been Imported?
No
Yes
Vehicle Modifications
Select Modifications
You have specified that the registered keeper or Vehicle owner is a private lease company, is the lease in the policyholder's name?
No
Yes
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Make and Model
Fuel Type
Diesel
Petrol
Petrol/Electric Hybrid
Diesel/Electric Hybrid
Electric
Engine Size
N/A
up to 1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3.0 or more
Year of Manufacture (yyyy)
Transmission
N/A
Manual
Automatic
Other
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Vehicle Modifications
Paintwork / Stickers
Badges indicating increased performance
Decals/stickers
Exterior decorative changes
Magnetic/Removable Signs
Murals
Non-standard paintwork
Non-standard respray
Respray (different colour)
Side stripes
Wheels / Tyres
Wheel Arches (non standard)
Wheel spacers
Wheels - Alloy
Wheels - Carbon
Wheels - Magnesium
Wheels - Wire
Wider Tyres
Wider Wheels
Accessories
Air conditioning
Car phone
Dashboard changes
Driving lights
Dual Controls
Emergency Services Blue Light
Fog Lights
High level/Extra brake lights
Interior changes
Locking Wheel Nuts
Parking sensors
Pedal Configuration (altered)
Rally/Spot Lights
Removal/Replacement of seats
Roll Cage/Roll Bars
Roof Rack
Satellite navigation system
Sports steering wheel
Sunroof
Tow Bar
Upholstery
Body modifications / Bodykit / Spoilers
Additional Windows
Body coloured bumpers
Bodykit (non standard)
Bodykit (optional extra)
Bonnet Bulge
Bonnet Bulge grill
Bull Bars
Carbon fibre bonnet
Complete Bodykit
Fibre glass panels
Modification due to disability
Rear roof spoiler
Rear spoiler/Aerofoil
Rear Valance
Side skirts/sills
Spoiler/Airdam - Front
Strenghtening brackets
Wheelchair modifications
Windows - Front Darkened >30%
Windows - Rear Darkened >30%
Windows - Tinted <30%
Wings (non standard)
Brakes / Suspension / Steering
Braided brake hoses
Brakes - uprated
Hand controls
Suspension lowered (<5cm)
Suspension lowered (5-12.5cm)
Suspension other (not lowered)
Engine / Transmission
Aftermarket Exhaust System - Approved for road use
Air Filter
Blueprinting
Engine - bored out
Engine - non standard
Engine - other alterations
Engine - standard replacement
Engine chip 00-10% inc BHP
Engine Chip 11-25% inc BHP
Engine chip 26%+ inc BHP
Exhaust/Manifold - Non Standard
Filters (non standard)
Gearing change
Liquid Petroleum Gas
Nitrous Oxide Kit
Supercharging
Transmission changes
Turbocharging
Other
Other
×
Van Modifications
Paintwork / Stickers
Badges indicating increased performance
Decals/stickers
Exterior decorative changes
Magnetic/Removable Signs
Murals
Non-standard paintwork
Non-standard respray
Respray (different colour)
Side stripes
Wheels / Tyres
Wheel Arches (non standard)
Wheel spacers
Wheels - Alloy
Wheels - Carbon
Wheels - Magnesium
Wheels - Wire
Wider Tyres
Wider Wheels
Accessories
Air conditioning
Car phone
Dashboard changes
Driving lights
Dual Controls
Emergency Services Blue Light
Fog Lights
High level/Extra brake lights
Interior changes
Larger speakers
Locking Wheel Nuts
Parking sensors
Pedal Configuration (altered)
Rally/Spot Lights
Refrigeration unit fitted
Removal/Replacement of seats
Roll Cage/Roll Bars
Roof Rack
Satellite navigation system
Side racks
Sports steering wheel
Sunroof
Tow Bar
Upholstery
Body modifications / Bodykit / Spoilers
Additional Windows
Body coloured bumpers
Bodykit (non standard)
Bodykit (optional extra)
Bonnet Bulge
Bonnet Bulge grill
Bull Bars
Carbon fibre bonnet
Complete Bodykit
Fibre glass panels
Modification due to disability
Rear roof spoiler
Rear spoiler/Aerofoil
Rear Valance
Side skirts/sills
Spoiler/Airdam - Front
Strenghtening brackets
Tail lift
Water tank fitted
Wheelchair modifications
Windows - Front Darkened >30%
Windows - Rear Darkened >30%
Windows - Tinted <30%
Wings (non standard)
Brakes / Suspension / Steering
Braided brake hoses
Brakes - uprated
Hand controls
Suspension lowered (<5cm)
Suspension lowered (5-12.5cm)
Suspension other (not lowered)
Engine / Transmission
Aftermarket Exhaust System - Approved for road use
Air Filter
Blueprinting
Engine - bored out
Engine - non standard
Engine - other alterations
Engine - standard replacement
Engine chip 00-10% inc BHP
Engine Chip 11-25% inc BHP
Engine chip 26%+ inc BHP
Exhaust/Manifold - Non Standard
Filters (non standard)
Gearing change
Liquid Petroleum Gas
Nitrous Oxide Kit
Petrol to diesel engine replacement - Professionally installed
Radiator bars
Supercharging
Transmission changes
Turbocharging
Other
Other
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www.collingwood.co.uk
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