Quotation Request Direct Test Scheme - shows html use Client Details Declarations Cover Details Notes Client Details Choose Package Gold Silver Bronze Elite Cover Commencement 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2025 Your NameThis will form the legal title of the policy -- Mr Mrs Miss Ms Dr Prof. Capt. Lord Lady Major Rev. Master Exec(s) of Mx Your Address UDPRN UPRN Organisation Line 1 Line 2 Town/City County Postcode Enter address manually or Enter address manually Use address lookup Your Mobile NumberYour phone number will be used solely for purposes of dealing with a Coincare insurance enquiryUse your landline number if this is more appropriate Your Email Address Email Email enter again Contact Address: SlipStream Underwriting, Unit 5, Avenue Business Park, Elsworth, Cambridge, CB24 3EY Email: [email protected]Tel: 01223 850 742Slipstream is a trading name of SchemeServe.SchemeServe is an appointed representative of XXXXXX who are authorised and regulated by the Financial Services Authority Declarations Have you or any partner or director or any other person responsible for managing the business in connection with this or any other business in which you or they have been trading ever been: Important Note: If you are proposing for cover on behalf of a business which is a company or partnership then the declaration extends to any director or partner in the business a) convicted or charge (but not yet tried) with any criminal offence other than motoring offences or spent convictions under the Rehabilitation of Offenders Act 1974? YesNo b) declared bankrupt, or been a director of a company that went in to liquidation or have any County Court Judgements or arrangements with creditor outstanding? YesNo c) declined my/our proposal or cancelled or refused my/our insurance, increased the premium, had special conditions imposed by an Insurer or had any Insurance terminated in respect of any of the risks proposed? YesNo d) the subject of a recovery action by Customs and Excise or the Inland Revenue? YesNo I/We declare that to the best of my/our knowledge and belief: The above statements and particulars, whether written by me/us or by others on my/our behalf, are true and complete and we have not witheld any material facts. YesNo Contact Address: SlipStream Underwriting, Unit 5, Avenue Business Park, Elsworth, Cambridge, CB24 3EY Email: [email protected]Tel: 01223 850 742Slipstream is a trading name of SchemeServe.SchemeServe is an appointed representative of XXXXXX who are authorised and regulated by the Financial Services Authority Cover DetailsBasic Premium £ Total Premium (Net) £0.00 + IPT @ % £0.00 + Policy Fee £ £0.00 Total Premium £0.00 Total Commission £0.00 (Due From Broker) £0.00 Additional NotesAdditional Notes