Motor Insurance Quote Request

Motor Insurance Quote Request
Name of Proposer

First Name Middle Name Last Name
E-mail of Proposer
Type of Cover *

Third Party Act Third Party Standard Comprehensive Comprehensive w/ Hurricane
Make of vehicle
Year
Type
Seating capacity
Registry No. or VIN
H.P., C.C., or CYL Size
Use *

Private Commercial
Will the vehicle be driven by any person under the age of 25? *

Yes No
Replacement Value BZ$
Annual Premium BZ$
Period of Insurance

Short- Term (three months) 1 Year
Optional Life Insurance Coverage
Applicant for Motor Vehicle Insurance Coverage is given the option to purchase a Life Insurance Policy for Named Person(s).
Coverage

Yes No
Number of Persons
Insurance History

State all previous claims.

Date

Amount Claimed