Name
*
First Name
Last Name
Email:
*
Town of Residence:
*
Please Select
Nicosia
Larnaca
Famagusta
Limassol
Paphos
Are you an existing client?
*
Νο
Yes - please give details (e.g. policy number, ID, account)
Phone Number
*
-
Area Code
Phone Number
Please enter your Date of Birth:
*
-
Day
-
Month
Year
Please enter your Licence date:
*
-
Day
-
Month
Year
Please choose your scheme/s of interest:
*
Third Party
Third Party Plus
Third Party Fire and Theft
Comprehensive
Comprehensive Executive
Enter your Motor Vehicle Reg.Num:
Please enter the Sum Insured:
List the market value of the vehicle
Enter the vehicle's Make/Model:
e.g. Toyota Icos, BMW 320i,
Engine Capacity (cc)
Please Select
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
>4000
Click on the Use of Vehicle
Private use
Commercial Use
Please choose one or both of the below options:
*
Named Driver
Any Driver (over 24 and below 70 years old)
Fill in the details for the named drivers:
Date of Birth
License Year
Occupation
Nationality
Driver 1
Driver
2
Driver
3
Driver
4
Driver
5
Driver
6
Please state if you or any of the named drivers had any claims in the last 5 years:
*
Yes
No
Claim details:
*
Claim Date
Claim Cost
Details
1
2
3
4
5
Important Notes:
1. Please note that this form is for quotation purposes only. If you wish to proceed with a contractual agreement you will be required to submit a proposal form. 2. Our quotation will be based on the information you have submitted, therefore, any alterations and/or misleading information, will cause a revision to the quotation accordingly. 3. We have collected only personal data you have voluntarily provided to us and which are processed solely for the purpose of risk assessment and preparation of this quotation.Where additional information is sought, you will be informed at the time of the data collection. If we do not conclude with a contract any personal data collected will be destroyed immediately. However, in case that you choose us for your policy, we are obliged by law to retain your personal data for a period of at least 13 (thirteen) years after termination.
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