Motor Insurance

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Please fill-in following form

Information about the subscriber

- Title


First name (required)


Last name (required)

Your Email (required)


Telephone (required)

-Town of residence (required)


Town ZIP Code :


Country of residence (required) :

Nationality (required) :


Date of birth (required) format dd/mm/yyyy

Profession (required) :

Date Driving Licence obtain (required) :

Are you married?

Have you got children?

Information about the car

Your car is used for :

N° 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) (required) :

Past claims declare all claims in the past three years - 36 months, responsible or not (required) :

Make / Model / Version of car for ex. Volkswagen / Polo / xxx (required) :


Serial Number of chassis (required) :

French Horse Power (required) :


When was it first registered (required) :

Gear box :

Fuel Type :

Parking :

Option :

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Please send me a free, no obligation, quotation based on the above :