express auto rate

Business introducer :
BUZZ ASSURANCES
Service Clients
BP 105
83061 TOULON Cedex
[email protected]
EXPRESS AUTO RATE
AUTOMOBILE INSURANCE
PROPOSAL FORM
DRIVERS :
y Policyholder : Name & Fisrt Name :
Date of birth : ____/____/______
Date of driving licence : ____/____/______
y Second user : Name & First Name :
Date of birth : ____/____/______
Date of driving licence : ____/____/______
y Address : ________________________________________________
_________________________________________________________.
y : ____/____/____/____/____
y Marital status :
y Occupation ;
Student
Salary
y Do you suffer from any physical or mental illness ?
No
Yes*
*If yes which illness
VEHICLE :
y Holder of vehicle registration certificate : Proposer Main user of vehicle
y Vehicle : Make Model :
Type :
Horsepower :
y Date of first time on road registration n°
y Vehicle use :
student
travel and pleasure
INSURANCE HISTORY
y During last 2 years :
Have you already been insured by a motor insurance policy in France ?
No
yes*
*If yes number of losses you have incurred or caused with tour vehicle.
y During last 3 years :
Suspension Revocation of licence ?
No
Yes*
*If yes, we can’t be insured by this policy.
Choice of covers (tick appropriate responses)
MINI Formula : Third Party + Legal Cover + Driver Cover
Standard Formula : Mini + Theft with excess + Fire (without excess) + natural disaster + Glass Breakage
DAMAGE Formula : Standard + All accident and vandalism with excess
Desired Inception date : _____/_____/_______
Declarations and signature of proposer:
I declare to have been advised that should the policy be cancelled the statement of information that will be delivered to me pursuant to the law,
shall be placed on a professional file managed by A.G.I.R.A. – 11 rue de Rochefoucaud – 75009 Paris. I also declare to have been advised
that membership is effected within the framework of group policies, that the due dates are fixed by the insurer and that my insurance policy
shall only be effective once the insurer has given his formal agreement and I have agreed to the proposed conditions.
I declare to have taken notice that articles L113/8 and L 113/9 of the Insurance Code shall apply, should, in the appraisal of the risk, the
companyhave been mislead due to non-disclosure or misstatement on my part.
MANDATORY SIGNATURE OF PROPOSER
preceded by the words “read and approved”
Drawn up in
on_
____/____/______
___
– For inception of any policy please attach to this proposal form:
The completed and signed quote, copy of the vehicle registration certificate.
A copy of the driving licence (both sides) and cash payment.
BP 237 – 17304 ROCHEFORT CEDEX – Tél : 05 46 99 31 60 Fax : 05 46 87 00 21
RC Rochefort B 378 849 798 – SA au capital de 52 450 € - ORIAS n° 07 000 579 consultable sur www.orias.fr
Entreprise soumise au contrôle de l’ACAM, 61 rue Taitbout 75009 Paris