French Car Insurance Request for Quote Form

French Car Insurance
Request for Quote Form
Where did you hear about us?
q Web Search
q Print ad or mailing
q Link or online ad
q Reffered by friend
q Other
Please specify website or publication, or enter Priority Code _______________________________________________________________________________________
Your car
_______________________________
_________________________________________
________________________________________
Make
Model and commercial version
Cylinder Capacity (CV) / fiscal horsepower
Serial No./type:
_____________________
Purchased: d_____ / m_____ / y_________
q Yes
Is the vehicle registered in France?
1st registration d_____ / m_____ / y_________
✔ No but will be by:
q
d_____ / m_____ / y_________
q No
Speed transmission
Fuel type
Body style
No. of doors
q Manual q Automatic
q Petrol q Diesel
q Sedan q Stat. wagon q SUV q Minivan q Coupe
q3
Primary usage: q Private
q Private and home/work commute
Night parking: q Closed garage
Place of parking:
Postal code:
q Private and professional
q Parking behind closed gates
_________________________
q5
q Sales
q Public parking or street
Town: ___________________________________________________________
Primary driver
First Name: ________________________________
Name: _________________________________________
_________________________________________________________________
________________________
______________________________________________
Address
Postal code
Place, State, Province, Country
Tel. in France: ________________________________________________
Tel. in home country:
Fax number:__________________________________________________
E-mail address:__________________________________________________________________________________
______________________________________________________________________
Date of birth:
d_____ / m_____ / y_________
Date of arrival in France:
d_____ / m_____ / y_________
Date of first licence:
d_____ / m_____ / y_________
Country where licence was issued: _____________________________
Car owner noted on vehicle’s registration: q Self q Spouse q Other (Please specify):________________________________________

French Car Insurance
Request for Quote Form
Insurance history
Bonus / penalty percentage (if applicable)
_____%
How many years of insurance could you justify?
Current policy’s inception date d_____ / m_____ / y_________
_____
Number of claims for which you were totally/partially liable
Number of claims for which you were not liable
Material damages to third parties: __________________________________
Glass breakage: ____________________________________________________
Material damages without third parties: __________________________________________
Material damage while car parked: __________________________
Bodily injury with third parties: ______________________________________________________
Thefts (or theft attempts): ______________________________________
Bodily injury without third parties: __________________________________________________
Others (please specify): _____________________________________________
Coverage
q Coverage 1:
q Coverage 2 = Coverage 1 + glass
Third party liability
q Coverage 3:
breakage, fire, theft and climatic events
Fully comprehensive
These data (your information) are meant to be dealt with and processed by Aon France in order to create a contact with you. You have a right
of access, modification, rectification and deletion on your information (French «Informatique et Libertés» Act of 6 January 1978). For any query,
please contact [email protected].
Please return completed form by fax: +33(0)-140-616-167
or post:
• In France, freephone: 0800 822 202
Aon Insurance for Expatriates
• Outside of France: +33-495-061-646
31-35 rue de la Fédération
• [email protected]
75717 Paris Cedex 15, France
• www.InsureXpat.fr
Aon Risk Solutions
Aon France : siège social | 31-35 rue de la Fédération | 75717 Paris Cedex 15 | w aon.fr
Société de courtage en assurances et réassurances immatriculée au Registre Unique des Intermédiaires d’Assurances sous le N° 07 001 560
SA au capital de 46 027 140 euros | 414 572 248 RCS Paris | N° de TVA intracommunautaire : FR 22 414 572 248
GARANTIE FINANCIÈRE ET ASSURANCE DE RESPONSABILITÉ CIVILE PROFESSIONNELLE CONFORMES AUX ARTICLES L512-7 ET L512-6 DU CODE DES ASSURANCES
Direction de la Communication - Le Studio -11.02.12/ARS - Septembre 2012
Number of claims submitted over the last 24 months ___