Honda WW (PCX)

First Name *

Middle Name

Surname *

Date of Birth *

Email Address *

Mobile number *

Street Address *

Town *

ZIP / Postal Code *

Country *

Marital Status *

How many children do you have?

What type of license do you have? *

Driver’s License number *

License Obtain Date *

Do you drive any other vehicles? Please, list *

Will anyone else be driving the bike? *

Car Owner? *

Home Owner? *

Job title *

Industry *

Please tell us your intended purpose for renting a moped. e.g delivery courier social etc... *

Do you have a valid CBT? *

Q1. Have you been involved in a motor accident in the past three years?YesNo

Q2. Have you made a claim against a motor insurer in the past three years?YesNo

Q3. Have you been convicted of a motor offence in the past five years?YesNo

Q4. Have you been disqualified from driving in the past eleven years?YesNo

Q5. Do you have any unspent criminal convictions?YesNo

Q6. Do you suffer from any physical or mental infirmity, diabetes, fits or heart complaint?YesNo

Q7. Have you ever been refused motor insurance, quoted an increased premium or had special terms imposed?YesNo

Who referred you? (refer a friend)

Promotional Code (if you have ove)

Date From *

Date To *

Driving License *

No file chosen

Valid CBT *

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Credit / Debit Card *

Deposit £250

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