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POST https://cloud.giinsurance.lv.com/renewal_capture/processing?qs=45386c71be0eca82513ad3a171bf10348cb9b15101999c70c17b4dc076f3dd55c1f4879129e9f3ecb1ff215c71d8b928eb1f780b31b276ec5b74f1dfd5d4467ad17af11749212d75ce300892aa832c8a9d9ec62a7b20143de762ad3828e15226a5b2c44b8304fa050c36b76971f3a89d

<form method="POST"
  action="https://cloud.giinsurance.lv.com/renewal_capture/processing?qs=45386c71be0eca82513ad3a171bf10348cb9b15101999c70c17b4dc076f3dd55c1f4879129e9f3ecb1ff215c71d8b928eb1f780b31b276ec5b74f1dfd5d4467ad17af11749212d75ce300892aa832c8a9d9ec62a7b20143de762ad3828e15226a5b2c44b8304fa050c36b76971f3a89d">
  <div>
    <fieldset>
      <div class="form__fieldset">
        <div class="form__fieldset__left">
          <legend>About you</legend>
          <h3>Tell us when your policies are up for renewal and we'll email you a month before to remind you to get a quote</h3>
        </div>
        <div class="form__fieldset__right">
          <div class="form-field form-field--email">
            <label class="form-field__label" for="email" data-label="Your Email Address"><span class="labelText">Your email address <em title="Required">*</em></span><span></span></label>
            <div class="form-field__field">
              <input type="text" class="lg " placeholder="Please enter your email address" name="email" id="email" value="dutton.jan@live.co.uk" required="" readonly="">
            </div>
          </div>
          <p class="footnote"><small>By giving us your email address, you agree to being contacted by email about offers and discounts on our products.</small></p>
        </div>
      </div>
    </fieldset>
    <fieldset>
      <div class="form__fieldset ">
        <div class="form__fieldset__left">
          <legend>When are your insurance policies due?</legend>
          <h2>When are your insurance policies due?</h2>
          <h3>You only need to let us know about the insurance policies you have</h3>
        </div>
        <div class="form__fieldset__right">
          <!-- Car -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="car_insurance_date"><span class="labelText">Car Insurance</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="car_insurance_date" name="car_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
          <!-- Second Car -->
          <!-- <div class="form-field form-field--date">
            <label class="form-field__label" for="second_car_insurance_date"><span class="labelText">Second Car Insurance</span></label>
            <div class="form-field__field">
             <div class="input-group datepicker">
              <input type="text" id="second_car_insurance_date" name="second_car_insurance_date" placeholder="DD/MM/YYYY" />
              <span class="input-group-addon">
               <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
              </span>
             </div>
            </div>
           </div> -->
          <!-- Electric Car -->
          <!-- <div class="form-field form-field--date">
            <label class="form-field__label" for="electric_car_insurance_date"><span class="labelText">Electric Car Insurance</span></label>
            <div class="form-field__field">
             <div class="input-group datepicker">
              <input type="text" id="electric_car_insurance_date" name="electric_car_insurance_date" placeholder="DD/MM/YYYY" />
              <span class="input-group-addon">
               <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
              </span>
             </div>
            </div>
           </div> -->
          <!-- Electric Car -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="electric_insurance_date"><span class="labelText">Electric Car Insurance</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="electric_insurance_date" name="electric_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
          <!-- Home -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="home_insurance_date"><span class="labelText">Home Insurance</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="home_insurance_date" name="home_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
          <!-- Landlord -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="landlord_insurance_date"><span class="labelText">Landlord Insurance</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="landlord_insurance_date" name="landlord_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
          <!-- Pet -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="pet_insurance_date"><span class="labelText">Pet Insurance</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="pet_insurance_date" name="pet_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
          <!-- Travel -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="travel_insurance_date"><span class="labelText">Travel Insurance</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="travel_insurance_date" name="travel_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
          <!-- Breakdown -->
          <div class="form-field form-field--date">
            <label class="form-field__label" for="breakdown_insurance_date"><span class="labelText">Breakdown Cover</span></label>
            <div class="form-field__field">
              <div class="input-group datepicker">
                <input type="text" id="breakdown_insurance_date" name="breakdown_insurance_date" placeholder="DD/MM/YYYY">
                <span class="input-group-addon">
                  <img class="datepicker-icon" src="https://image.giinsurance.lv.com/lib/fe33117075640475731578/m/1/calendar-green.png" alt="Calendar">
                </span>
              </div>
            </div>
          </div>
        </div>
      </div>
    </fieldset>
    <div class="form-field form-field--button">
      <button class="cta cta--sm cta--primary cta--no-icon" type="submit" name="submit" value="Submit">Submit</button>
    </div>
  </div>
</form>

Text Content

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NEED A LITTLE REMINDER?

About you


TELL US WHEN YOUR POLICIES ARE UP FOR RENEWAL AND WE'LL EMAIL YOU A MONTH BEFORE
TO REMIND YOU TO GET A QUOTE

Your email address *


By giving us your email address, you agree to being contacted by email about
offers and discounts on our products.

When are your insurance policies due?


WHEN ARE YOUR INSURANCE POLICIES DUE?


YOU ONLY NEED TO LET US KNOW ABOUT THE INSURANCE POLICIES YOU HAVE

Car Insurance

Electric Car Insurance

Home Insurance

Landlord Insurance

Pet Insurance

Travel Insurance

Breakdown Cover

Submit
 * Insurance
 * Need a little reminder?

LV= and Liverpool Victoria are registered trademarks of Liverpool Victoria
Financial Services Limited and LV= and LV= Liverpool Victoria are trading styles
of the Liverpool Victoria General Insurance group of companies. Liverpool
Victoria Insurance Company Limited, registered in England and Wales number
3232514 is authorised by the Prudential Regulation Authority and regulated by
the Financial Conduct Authority and the Prudential Regulation Authority,
register number 202965. Registered address: 57 Ladymead, Guildford, Surrey, GU1
1DB. Tel: 0330 123 9970.