Car insurance: Request for a quotation (Ref: 12111-P.EL)
Name: ____________________________________
Address in France: ___________________________________________________
____________________________________________________________________
Tel: ________________ Fax: _______________ E-mail: _____________________
Date driving license issued: ________________ Date of birth: _______________
Occupation: ______________________
Approx. annual mileage: ____________________
Brand / Type of car: _______________________ Example: Peugeot 206
Model: _______________________ Example: 2 litres HDI - Please be as precise as possible
2/3doors • 4/5 doors • chassis number: _______________________
Date of manufacture (month + year) ______________
Car usage: ____________________ Example: leisure, journey to work, business purposes
How long have you been insured in the UK for your previous cars: _________ years
No claims discount: ________ years
Have you made a claim over the last three years: Yes • No •
If Yes please give details:
Nature: ___________________________________________ Date: ___________ Liability: _____ %
Nature: ___________________________________________ Date: ___________ Liability: _____ %
Nature: ___________________________________________ Date: ___________ Liability: _____ %
Nature: ___________________________________________ Date: ___________ Liability: _____ %
Would it be possible to obtain a certificate / letter from your previous and existing
insurers confirming how long you have been insured with them and if you have
had a claim ? Yes • No •
(we can contact them ourselves if you give us their details)
If Yes, what period would that cover?: _______ years
Please note that the best quote is obtained if we can get a confirmation (fax or letter / policy
documents from previous insurers) that you have been insured for at least thirteen years
Type of cover: • Fully comprehensive
• Public liability + theft + fire
• Public liability only
Please send the completed form to Thierry M