| Full name: |
*
|
| Date of Birth: |
Day:Month:Year:*
|
| Occupation: |
*
|
| Address: |
|
| Post code: |
*
|
| City: |
|
| Telephone: |
*
|
| Fax: |
|
| E-mail: |
|
|
|
Motor Vehicle information
|
|
Owner:
Private
Company
|
| Registration Number: |
|
| Year First Registered: |
* |
| Type of vehicle: make, model and year*
|
-
*
|
| Number of seats: |
|
| Roof Rack: |
YES
NO |
| Tow hook for trailer: |
YES
NO *
|
| Tow hook for trailer: |
€
|
|
Value of accessories/equipment not standard:
|
€
*equipment permanently fitted and not incorporated into the basic price of the vehicle |
| Kilometres travelled (per year) |
Km. |
| Current/previous insurance
details: |
Do you have current
insurance?
YES
NO
Type:
Comprehensive
Third Party |
Do you have a no claim discount with the current insurance?
YES
NO % |
| Details of the main driver: |
| Date of birth: |
Day:Month:Year:*
|
| Driving Licence issued on: |
Day:Month:Year:*
|
| Sex: |
Male
Female
* |
| Marital status: |
* |
| If the vehicle will be driven occasionally by a person of 25 years or
younger, and/or with less than 2 years experience, indicate the date of
birth, driving licence details, sex and marital status. |
|
| Please indicate which cover you wish for the
quotation: |
- Third-party only
(1)
- Third-party with
windscreen/windows
- Third-party with
windscreen/windows, and theft
- Third-party with
windscreen/windows, fire and theft
- Comprehensive without excess
- Comprehensive with excess
- (1)
For private cars and
similar: Compulsory liability and supplementary unlimited
Civil Liability, legal protection, bail bond and claims,
driver’s personal accident, medical expenses and travel
assistance.
For others types of vehicles (motorbikes/motor homes/commercial vehicles): please specify
|
Additional Information:
|
| I would like to receive the information by: |
E-mail
Fax
Telephone
Mail
A personal visit from the broker
In person in Duñach's office in Roses
In person in Duñach's office in Empuriabrava
|