Vehicle Quotation Information Form

Please complete all fields. ALL questions marked with * are required. If not applicable, please enter "n/a"

First Name:

Last name:

Birthday

Day

Month

Year

Email

Phone

Work Phone

Occupation

Employer

City, state/province, country

Island, settlement

Year driver's license obtained

Make and model of vehicle

Year

Engine Size

Body Type

Date Purchased

Serial Number (VIN)

Price Paid

Was the vehicle duty free?

Yes

No

What will the vehicle be used for?

On which island will the vehicle be used primarily?

Coverage Sought

Comprehensive (Maximum vehicle age: 8 years)

Third Party

Third Party Fire & Theft (Maximum vehicle age: 5 years)

Do you own the vehicle?

Yes

No

If not, please provide name and contact details of registered owner

If the car has a loan, please provide the name on the loan

Will anyone under the age of 25 be driving the vehicle?

Yes

No

If yes, please provide date of birth

Has vehicle been modified or fitted with oversized tires or high performance engine or equipment?

Yes

No

Has the vehicle ever been in an accident or declared a Total Loss or Salvage?

Yes

No

Please provide details of any existing vehicle damage

Have you or anyone likely to drive the vehicle:

Held a full driver's license for less than 2 years?

Yes

No

If YES, please provide date(s) license was obtained

Been involved in any accident during the last 5 years, whether it was your fault or not?

Yes

No

If YES, please provide details of accident

Been charged with a motoring offense?

Yes

No

If YES, please provide details

Suffer from any physical or medical condition?

Yes

No

If YES, please provide details

Please provide the following information for all persons likely to drive the vehicle: name, relationship to proposer, date of birth, occupation/place of employment, year drivers license obtained