Quotation form for motor insruance

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Information about the subscriber

Title*

First name*

Last name*

Town of residence*

zip code*

Country of residence*

Profession*

e-mail*

Phone*

Date of birth*

Date of driving licence*

Nationality*

Are you married ?*

Have you got children ?*

Information about the car

Your car is used for :*

Coefficient of Claim Bonus - (example: coefficient such as 0.80 for 20% NCB) or details of claims over last 10 years for foreigners without proof of NCB) : *

Past claims declare all claims in the past three years - 36 months, whether responsible or not :*

Make / Model / Version of car for ex. Volkswagen / Polo / xxx :*

Serial Number of chassis :*

Horse power (known on registration document as fiscal horse power) :*

When was it first registered*

Gear box :*

Fuel type : *

Parking : *

Veuillez saisir les caractères*

Cela nous aide à éviter les spams, merci.