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Auto Insurance

Comprehensive Auto Insurance

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Personal Information

Name / Surname:

Age:

Address:

E-Mail:

Tel/Fax:

Occupation:

Other Details

Type of Insurance (State cover required)
	Comprehensive
	Thrid party Fire & Theft
	Thrid party only (compulsary)

Particular of vehicles

Registration mark & no:

Engine No:

Make

Chasis No:

Type of body::

Seating capacity including driver:

Horse power or cc:

Year of manufacture:

Date of purchase:

Present value inc. accessories:

Price paid by proposer:

Will the vehicle(s) be driven by the:

Insured

Paid driver

Anyone else

Previous experience of motor driving, number and the date of licence:

At what address is/are the vehicle(s) usually garaged?

Is it/are they normally kept in locked premises at night?

If you desire a premium reduction please state;

Previous insurance company name :

No claim bonus:

Increasing excess:

I/ we declare that the above answers are the best of my/our knowledge and belief that all material factors affecting the assessment of the risk have been disclosed. I/ we agree that this proposal is for insurance in the standard terms and conditions of the insurers policy and shall be the basis of the contract.