Izlatop Insurance Agency — Bepul narx olish / Get a Free Quote / Получить бесплатный расчёт

1
To'liq ismingiz / Full name / Полное имя* This field is required.
First Name
Last Name
2
Middle initial (ixtiyoriy / optional / необязательно)
3
Tug'ilgan sana / Date of birth / Дата рождения* This field is required.
Date
Month
Day
Year
4
Ariza yuborish / Submit / Отправить* This field is required.
Erkak / Male / Мужской
Ayol / Female / Женский
5
Email manzilingiz / Email address / Ваш email* This field is required.
example@example.com
6
Telefon raqamingiz / Phone number / Номер телефона* This field is required.
Please enter a valid phone number.
7
Hozir qayerda yashaysiz? / Where do you currently live? / Где вы сейчас живёте?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Oxirgi 2 oy ichida ko'chdingizmi? / Moved in last 2 months? / Переезжали за последние 2 месяца?* This field is required.
Ha / Yes / Да
Yo'q / No / Нет
9
Maxfiylik bildirishnomasi / Privacy Disclosure / Политика конфиденциальности * This field is required.Biz siz bergan ma'lumotlar va boshqa manbalardan — driving history, claims history va credit historydan foydalanib sug'urta narxini hisoblaymiz. Yangi ma'lumotlar renewal narxiga ta'sir qilishi mumkin. Privacy policy nusxasini so'rashingiz mumkin. / We use your driving, claims and credit history to calculate your insurance price. New information may affect your renewal premium. A copy of our privacy policy is available upon request. / Мы используем историю вождения и кредитную историю для расчёта стоимости страховки. Копия политики конфиденциальности доступна по запросу.
Roziman / Agree / Согласен
Rozi emasman / Disagree / Не согласен
10
Avtomashinangizni VIN raqami kiriting / VIN number / VIN номер* This field is required.VIN raqamini yozing / Type your VIN / Введите VIN
11
Mashinani asosan nima uchun ishlatasiz? / How do you mainly use your car? / Для чего в основном используете авто?* This field is required.
Shaxsiy maqsadda / Personal use / Личные поездки
Biznes uchun / Business / Для бизнеса
Ishga qatnash / Commute / На работу
Fermerlik / Farm / Фермерство
12
⚠️ Agar Uber, Lyft, DoorDash yoki boshqa delivery/rideshare ishlatilishi ko'rsatilmasa, sug'urta kompaniyasi ish vaqtida avariya bo'lsa to'lovni rad etishi mumkin. / ⚠️ If rideshare or delivery usage is not disclosed, the insurance company may deny the claim and refuse payment after an accident. / ⚠️ Если не указать использование для Uber, Lyft, DoorDash — страховая компания может отказать в выплате после аварии.
13
Uber, Lyft, DoorDash ishlatasizmi? / Do you use rideshare or delivery? / Используете Uber, Lyft, DoorDash?* This field is required.
Ha / Yes / Да
Yo'q / No / Нет
14
Yiliga qancha mil yurasiz? / How many miles per year? / Сколько миль в год?* This field is required.
0–5,000
5,001–10,000
10,001–12,000
12,001–15,000
15,001–20,000
20,000+
15
Mashina siznikimi, ijara yoki kreditdami? / Is the vehicle owned, leased or financed? / Автомобиль ваш, в lease или finance?* This field is required.
Own / O'zimniki / Моя собственность
Lease / Ijara / Аренда
Finance / Kredit / Кредит
16
Oilaviy holat / Marital Status / Семейное положение* This field is required.
Single / Turmush qurmagan / Не женат/замужем
Married / Turmush qurgan / Женат/замужем
Divorced / Ajrashgan / Разведён/а
Widowed / Beva / Вдовец/вдова
17
Haydovchilik guvohnomasi turi / Driver License Type / Тип водительских прав* This field is required.
Regular / Oddiy / Обычные
Commercial (CDL)
Permit / Vaqtinchalik / Временные
Foreign / Xorijiy / Иностранные
None / Yo'q / Нет
18
Guvohnoma shtati / License State / Штат прав* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
19
Guvohnoma raqami / License Number / Номер прав
20
SR-22 kerakmi? / Do you need SR-22 filing? / Нужен SR-22?* This field is required.
Ha / Yes / Да
Yo'q / No / Нет
21
Haydovchilik guvohnomanizi qachon oldingiz? / When did you get your license? / Когда вы получили права?* This field is required.
1 yildan kam / Less than 1 year / Менее 1 года
1–2 yil / 1–2 years / 1–2 года
3–5 yil / 3–5 years / 3–5 лет
6–10 yil / 6–10 years / 6–10 лет
10 yildan ko'p / More than 10 years / Более 10 лет
22
Bandlik holati / Employment / Занятость* This field is required.
Ishlayman / Employed / Работаю
O'z biznesim / Self-employed / Свой бизнес
Ishsiz / Unemployed / Не работаю
Talaba / Student / Студент
Nafaqada / Retired / На пенсии
23
Kasb / Occupation / Профессия* This field is required.
24
Boshqa haydovchi qo'shmoqchimisiz? / Do you want to add another driver? / Хотите добавить ещё одного водителя?* This field is required.
Ha / Yes / Да
Yo'q / No / Нет
25
Haydovchining to'liq ismi / Driver full name / Полное имя водителя* This field is required.
First Name
Last Name
26
Oilaviy holat / Marital Status / Семейное положение* This field is required.
Single / Turmush qurmagan / Не женат/замужем
Married / Turmush qurgan / Женат/замужем
Divorced / Ajrashgan / Разведён/а
Widowed / Beva / Вдовец/вдова
27
Munosabat / Relationship / Отношение к страхователю* This field is required.
Spouse / Turmush o'rtog'i / Супруг/а
Child / Farzand / Ребёнок
Parent / Ota-ona / Родитель
Other / Boshqa / Другое
28
Tug'ilgan sana / Date of birth / Дата рождения* This field is required.
Date
Month
Day
Year
29
Jins / Gender / Пол* This field is required.
Erkak / Male / Мужской
Ayol / Female / Женский
30
Haydovchilik guvohnomasi turi / Driver License Type / Тип водительских прав* This field is required.
Regular / Oddiy / Обычные
Commercial (CDL)
Permit / Vaqtinchalik / Временные
Foreign / Xorijiy / Иностранные
None / Yo'q / Нет
31
Guvohnoma shtati / License State / Штат прав* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
32
Guvohnoma raqami / License Number / Номер прав
33
SR-22 kerakmi? / State Filing SR-22? / Нужен SR-22?* This field is required.
Ha / Yes / Да
Yo'q / No / Нет
34
Haydovchilik guvohnomanizi qachon oldingiz? / When did you get your license? / Когда вы получили права?* This field is required.
Date
Month
Day
Year
35
Bandlik holati / Employment / Занятость* This field is required.
Ishlayman / Employed
O'z biznesim / Self-employed
Ishsiz / Unemployed
Talaba / Student
Nafaqada / Retired
36
Kasb / Occupation / Профессия* This field is required.
Should be Empty: