Auto Insurance
Auto Insurance Comprehensive Auto Insurance
Insurance Form
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.