La Playa Private Client: Insurance with Intelligence

Motor Insurance Fact Find

Please complete this form as far as possible. If you're new to La Playa, the Private Client team will be in touch within 24 hours. Otherwise, your dedicated broker will acknowledge safe receipt shortly after your submission.

This form automatically saves the information you type into it. So you do not need to fill it in all in one go. Just return to this page and your information will still be here until you Submit the form to us.



Client Details










Home Address







Partner / Spouse






Existing Insurance





Vehicle 1








Is the vehicle left hand drive?: Yes No

Any modifications?: Yes No


Garaged overnight?: Yes No


Is a Tracker installed?: Yes No


Is NCD protected?: Yes No


Have you or any of the Named Drivers had any claims within the last 6 years?: Yes No




Vehicle 2








Is the vehicle left hand drive?: Yes No

Any modifications?: Yes No


Garaged overnight?: Yes No


Is a Tracker installed?: Yes No


Is NCD protected?: Yes No


Have you or any of the Named Drivers had any claims within the last 6 years?: Yes No




Vehicle 3








Is the vehicle left hand drive?: Yes No

Any modifications?: Yes No


Garaged overnight?: Yes No


Is a Tracker installed?: Yes No


Is NCD protected?: Yes No


Have you or any of the Named Drivers had any claims within the last 6 years?: Yes No




Vehicle 4








Is the vehicle left hand drive?: Yes No

Any modifications?: Yes No


Garaged overnight?: Yes No


Is a Tracker installed?: Yes No


Is NCD protected?: Yes No


Have you or any of the Named Drivers had any claims within the last 6 years?: Yes No




Vehicle 5








Is the vehicle left hand drive?: Yes No

Any modifications?: Yes No


Garaged overnight?: Yes No


Is a Tracker installed?: Yes No


Is NCD protected?: Yes No


Have you or any of the Named Drivers had any claims within the last 6 years?: Yes No




Vehicle 6








Is the vehicle left hand drive?: Yes No

Any modifications?: Yes No


Garaged overnight?: Yes No


Is a Tracker installed?: Yes No


Is NCD protected?: Yes No


Have you or any of the Named Drivers had any claims within the last 6 years?: Yes No




Details of Driver 1






Any Convictions: Yes No

Any Claims: Yes No

If you answered Yes to any of the above, please provide details:


Details of Driver 2






Any Convictions: Yes No

Any Claims: Yes No

If you answered Yes to any of the above, please provide details:


Details of Driver 3






Any Convictions: Yes No

Any Claims: Yes No

If you answered Yes to any of the above, please provide details:


Details of Driver 4






Any Convictions: Yes No

Any Claims: Yes No

If you answered Yes to any of the above, please provide details:


Please confirm the following

You or anyone to be covered by this insurance have never been convicted of and/or charged with any offence (other than motoring convictions and/or spent convictions):* Yes No

You or anyone to be covered by this insurance have never been the subject of any:

bankruptcy proceedings:*  Yes No
debt relief order:*  Yes No
individual voluntary arrangement (IVA):*  Yes No
County Court Judgment (CCJ):*  Yes No

You or anyone to be covered by this insurance have never had insurance:

cancelled:*  Yes No
refused:*  Yes No
declined:*  Yes No
If you answered Yes to any of the above, please provide details:

How did you hear about La Playa?:
Web search
La Playa marketing
Referral from somebody
Please give details:*


Your Insurance Priorities

Please briefly outline the 3 priorities that are key to your insurance needs and wants.




The questions we ask in this Application Form will help us establish your insurance requirements (“demands and needs”) and will form the basis of the quotation(s) we obtain for you. This will help us to better understand your situation and allow us to present the most appropriate solution.

Information Provided by You
It is your continuing duty to answer all of our questions in preparing this quotation honestly and, having taken reasonable care, to the best of your knowledge. This helps us ensure that your policy terms and conditions are correct. Please therefore carefully check the information you have provided in answer to our questions, to ensure that it's accurate.

Any other relevant information:

Data Protection ACT 1998 – Client's consent clause
In order to prepare a report and/or quotation in response to your enquiry, we'll need to process the details you've given us on our computer system and share them with the insurers and premium instalment providers we ask to quote.

By signing this form and/or making an application for this insurance, you're consenting to the information being processed by insurers, or by their agents, so that they can provide insurance and claims handling. To do this, they may need to provide some information to third parties, for example loss adjusters.