Autoverzekering Formulier

PERSONAL DATA

Driver's first name(s)

Driver's last name(s)

Email address

Phone number (only numbers, no + and no spaces)

Street address + number

Postal code

City

NIF (DNI/NIE)

Date of birth

Date of driver's license

Issuing country of driver's license

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VEHICLE DATA

Make

Model

Exact version

License plate number

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INSURANCE POLICY

Do you have a current insurance policy?
YESNO
If so, please complete:
Insurance company

Policy number

Insured license plate number

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DESIRED COVERAGE

Third party (incl. glass breakage)Third party (incl. theft, fire, and glass breakage)All risks (no deductible)All risks with deductible (indicate deductible amount below)
All risks deductible amount (the out-of-pocket cost when declaring a claim):
NoneMax. 200 EURMax. 600 EURMax. 1000 EURMax. 1500 EUROver 1500 EUR

Accessories to be covered by All Risks policy (optional):

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FORM OF PAYMENT

Select one:
AnnuallySemi-annuallyQuarterly

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Additional information (only if Owner of the vehicle is not the same as the Driver):
Vehicle owner's first name(s) - if different from Driver's

Vehicle owner's name(s) - if different from Driver's

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