20 años, seguro que los recuerdas


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C/. Pintor Murillo, 39 bajo
03760 Ondara (Alicante)
Tel.: 96 576 73 57
Fax: 96576 74 05
info@segurosoliver.com

Automobile and motorcycle insurance

 

Fill in the following, remember spaces with asterisk (*) must be filled in.

CONTACT DETAILS

Your name (*):

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Your telephone number or e-mail (*)

You must provide your contact form

Your zip code (*):
Tell us your zip code

VEHICLE DETAILS




Make (*)
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Model (*)
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Version (*)
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License Plate (*)
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Town (*)
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Max. Authorised weight (*)
Kg.
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(Only in case of lorries or industrial vehicle)

C.C. (*)
cc
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Year of first registration (*) (dd/mm/yyyy)
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Year of purchase (*) (dd/mm/yyyy)
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Vehicle is kept in a garage during the night (*)
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Tow bar (*)
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Intended Use (*)
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Loader-Unloader (*)
(Only in case of lorries or industrial vehicle)
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Accessories (details and prices)

PERSON TO BE INSURED


 
Usual Driver

Date of birth(*) (dd/mm/yyyy)
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Date of driving licence (*) (dd/mm/yyyy)
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Sex (*)
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Marital status (*)
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Do you have no claim bonus with your present company? (*)
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Indicate the following information:
N.I.E. of driver::

Name of the company::

Policy Number:

Are you Spanish? (*)
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In case you are not Spanish::
Country of origin::

Are you resident?

Type of driving licence (*)
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Other drivers

Date of birth (dd/mm/yyyy)

Date of driving licence (dd/mm/yyyy)

Sex

Marital status


OWNER DETAILS

 
He/She is the usual driver

Date of birth(*) (dd/mm/yyyy)
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Date of driving licence (*) (dd/mm/yyyy)
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Sex(*)
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COVER YOU WISH US TO QUOTE







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