Car Form
Paul BOUSSARD - ALLIANZ
About you
Title
Mr
Mrs
First name
Surname
Your date of birth
-
Mois
-
Jour
Année
Date
Your address
Your email address
Your phone number
Your nationality
Your family situation
Single
Married
Partened
Widow
Your occupation
Employed
Self-employed
Retired
Other
Your driving licence date
-
Mois
-
Jour
Année
Date
Have you had Motoring convictions in the last 3 years
Yes
No
Have you had any claims in the past 3 years
Yes
No
What is your NCD or French bonus ?
Retour
Suivant
Your partner
Do your partner to be named on policy ?
Yes
No
His/her driving licence Date
-
Mois
-
Jour
Année
Date
Has he/she had Motoring convictions in the last 3 years
Yes
No
Has he/she had any claims in the past 3 years
Yes
No
What his/her NCD or French bonus ?
Retour
Suivant
Your car
Make
Model
Version
Fuel Type
Year of manufacture
Registration number
Date of Purchase
How will the car be used
Socially
Socially and driving to and from a workplace
Socially and driving to and from a workplace and for business use
How many miles will the car be driven over the next year ?
Under 7000km
Under 9000km
More than 9000km
Overnight park
Drive
Street
Locked garage
Retour
Suivant
The covers you want
Base
Third party only ( C1)
Third party, fire, thiefs and glass break ( C2 )
Comprehensive ( C3 )
Additional
Roadside & home assist
Hire car
Soumission
Should be Empty: