APPLICATION FORM FOR A MOTOR INSURANCE QUOTE NOTE: Please don't use the enter/return key on your keyboard until you complete the form; it results in the form being sent before it has been completed! - You can use the tab key to move to the next line.
PROPOSER
Surname
First name
Date of birth	-- dd/mm/yy
E-mail
Tel
Fax
Mobile
Address (in France)
Town
Postcode
Occupation
Status
Date of 1st driving license	-- dd/mm/yy

INSURANCE HISTORY
N° Years insured - in France
...in UK
...in another country
Have you been insured for the past 3 years?	Yes......... No
How many months interruption of insurance during the past 12 months?
No Claims Bonus or Coefficient Bonus/Malus shown on your present/last insurance certificate
Name of your previous / current insurance company
Policy No.
Date of cancellation...	-- dd/mm/yy
...or next renewal date	-- dd/mm/yy

CLAIMS HISTORY IN THE PAST FIVE YEARS	(Please answer by '0' if none)
Number of RESPONSIBLE MATERIAL accidents	....
Date of each one	........
Number of RESPONSIBLE BODILY accidents	....
Date of each one	........
Number of PARKING accidents	....
Date of each one	........
Number of THEFTS	....
Date of each one	........
Number of FIRES	....
Date of each one	........
Number of GLASS BREAKAGE	....
Date of each one	........

DRIVERS
Main user - Surname & First name
Main user - Date of birth	-- dd/mm/yy
Main user - Date of 1st driving licence	-- dd/mm/yy
Main user - Occupation
Spouse - Surname & First name
Spouse - Date of birth	-- dd/mm/yy
Spouse - Date of 1st driving licence	-- dd/mm/yy
Spouse - Occupation
1st Child < 26 years old - Surname & First name
1st Child - Date of birth	-- dd/mm/yy
1st Child - Date of 1st driving licence	-- dd/mm/yy
1st Child - Occupation
2nd Child < 26 years old - Surname & First name
2nd Child - Date of birth	-- dd/mm/yy
2nd Child - Date of 1st driving licence	-- dd/mm/yy
2nd Child - Occupation
HAS ONE OF THE DRIVER'S LICENCES BEEN WITHDRAWN FOR MORE THAN 1 MONTH IN THE LAST 3 YEARS?	Yes......... No
If yes give details

VEHICLE DETAILS	(Please look at your 'Carte Grise' / registration document)
Make
Exact model
Body
N° Doors
Diesel	Yes......... No
Turbo diesel	Yes......... No
Petrol	Yes......... No
Automatic gearbox	Yes......... No
Horse power in CC
Puissance in CV (french)
Serie No.
Date of 1st registration	-- dd/mm/yy
Registration/Immatriculation N°
Value as NEW in Euros
Estimated current value in Euros
Do you have a locked garage for it?	Yes......... No
Is the car equipped with a certified burglar alarm or immobiliser system?	Yes......... No

COVER REQUIRED
Comprehensive	Yes......... No
Third Party + Fire & Theft + Glass breakage	Yes......... No
Third Party only	Yes......... No
DATE OF INSURANCE REQUIRED COMMENCING ON:	-- dd/mm/yy