Insurance Quote Form

Hirer Details

If this form is not working, please simply get in touch and we can process via email - click here for a list of information we require. KokoroShinro@gmail.com

Trip date & duration

First date of hire (dd/mm/yy) Insure for how many days? You may estimate the date and duration if you are not ready to book yet. We can re-quote at a later date.

Title

Title*

Name

First Name Middle Name Last Name

Date of Birth

(To select Year quickly, tap current year at Top Left and Scroll)

Date of Birth*

Address Details

Postcode* Address* (Must match Drivers Licence of Main Driver)

Contact Information

Mobile Telephone Email Address*

Occupation

If your occupation is not listed, select 'Employed but Not Listed', then add your Occupation (1st & 2nd) in the Box below.

Main Occupation* Secondary Occupation* Unlisted Occupation(s)

Licence Information

Licence Number* For international drivers, enter any relevant Numbers/Codes that uniquely identifies your License.

Visit DVLA to request a Licence Check Code (opens in New Window)

Licence Check Code (UK Only)* By supplying your Licence Number & Check Code, you are granting us and our Insurance Broker persmission to view your DLVA License Overview.
For International Drivers, please enter 'NA'

License Type* License Country of Issue* License Expiry Date* Period License Held*

Driver has Motoring Convictions?

This form will accept 2 Convictions, if you have a 3rd or more, please email us to discuss cover. Yes No

Conviction 1

Conviction Code: Date of Conviction: Penalty Points: Amount of Fine (£) (Enter 0 if no fine was given) Did this conviction result in a driving disqualification?

Yes No

Duration of Disqualification

Conviction 2

Conviction Code: If no further Convictions, please select 'NO SECOND CONVICTION from the list' Date of Conviction: Penalty Points: Amount of Fine (£) (Enter 0 if no fine was given) Did this conviction result in a driving disqualification?

Yes No

Duration of Disqualification

Driver has had previous Incidents?

This form will accept 2 Incidents, if you have a 3rd or more, please email us to discuss cover. Yes No

Incident 1

Incident Type Date of Incident Estimated Cost of Own Repairs (£) Estimated Cost of 3rd Party Repairs (£)

Incident 2

Incident Type Date of Incident Estimated Cost of Own Repairs (£) Estimated Cost of 3rd Party Repairs (£)

Non-motoring Convictions

Do you have any Non-motoring Convictions, previously or pending?

Yes No

I confirm that all the information provided is accurate and I have read and agree to the Privacy Policy and Terms & Conditions.

I understand that Kokoro Shinro Ltd will passs this to InsureCarHire.co.uk so thay may Quote & Provide Insurance Cover.

Kokoro Shinro Ltd will store this Data in accordance with GDPR Guidelines and for only as long as the Law Requires us to. Refer to InsureCarHire.co.uk for their specific T&Cs & Data Policies.

Copies of the Insurance Documentation can be viewed here - they are provided for reference only and are not legally binding, you must refer to the latest documentation provided by the insurance company.