About you:
Title:	Mr Mrs Ms.
First Name:
Last Name:
E - mail:
Address Line1:
Address line2:
Town / City:
Post Code:
Home Tel:
Work Tel:
Age:
Marital Status:	Married Single
No. of children:

Your car and driving habits:

Vehicle Make:
Vehicle Colour:
Vehicle Model:
Number of Doors (including hatchback):
Year:
Registration Number:
How many hours per day do you spend in your car?
How many miles do you do in total per year?
per month?
How many of these are on business?
Do you regularly use a motorway?	Yes:No:
If Yes which ones:
How many miles are spent in commuting to and from work/school?
is the approximate distance from home to work/school?
At home where is your vehicle parked?	On my drive at home In a public open air car park In a private covered car park In my garage On a busy road On a quiet road
Is your car visible by others when it is parked overnight?	Yes;No:
During the day where do you park your vehicle?	In a public open air car park In a private covered car park On a busy road On a moderate road On a quiet road
At work can you car be seen from the street?	Yes:No:
When your car is parked at work, how many people can see it?	Not very many Some A lot Not very many

Your work:
Are You:	Professional Executive Junior Management Salaried Clerical Hourly Paid
Do you have professional qualifications:	Yes:No:
Do you have a University Degree:	Yes:No:
Annual salary:	£10,000 - £20,000 £20,000 - £40,000 £40,000 - £70000 Over £70,000
Your shopping habits:
Do you regularly shop at a supermarket?	Yes:No:
If Yes how many times per month:
Approximately how far away is your supermarket from you:
How many times per month do you take your car to shop in the High Street?	Never 1-2 3-8 Over 8
Approximately how far away is your High Street from you?
How many times per month do you visit a restaurant by car.
How far away is your favourite restaurant?
How many times per year do you use your car for holidays/weekend breaks:	I don't 0-1 2-4 4-6 7 or more

Recreation:
Do you visit a weekend home by car?	Yes: No:
If yes, how far it from your regular home?
How many times per year do you visit it?
Do you regularly visit a health or sports centre by car?	Yes: No:
If Yes how often per week:	1-2 3-4 4-7 Over 7
How far is the health or sports centre from you (one way)?	0-3 miles 4-6 miles 7-10 miles Over 10 miles
Using you car, which other recreational activities do you participate in (tick where applicable):
Angling
Golf
Motor Sport
Football
Rugby
Horse Racing
Concert Going
Walking Hiking
Sailing
Surfing/Windsurfing/Body boarding

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