COMPREHENSIVE AUTO POLICY FORM


Kasra A.Ş.

Name and Surname of the Owner
(Or the name of the company)

 :  *

E-Mail

:  *

Daytime Telephone

: ( )  *

Mobile Telephone

: ( )

Fax

 : ( )

Best Time To Call

 :

Date of Birth

 : dd/mm/yy
Details of the vehicle
Manufacture Year :
Make :
Model :
Type & Body :
Usage :
Engine Capacity :
Gear Type :
Number of vehicle owned by the insured :
City Plate Code :
Actual Value of the Vehicle :
Current Insurance
Current Insurance Company :
Expiration date of the current auto insurance policy : /
No claim reduction applied to your current comprehensive policy : %
Have you had an accident in the past 12 month? : Yes No
If yes the nature of the claim? : Body / Paint
Glass
Audio Equipment Theft
Was the fault at you? : Yes No Partly
Special Information
Would you like a driver limited policy and have a further reduction ? : Yes No
Insured driving only : Yes No
Insured and spouse driving : Yes No
2 named drivers : Yes No
Year of birth :
Years licensed to drive :
If you have any other car insured in our company, please state the number of comprehensive policies. :
Policy type required : Third Party
Fire and Theft Only
Comprehensive
Your reference for deduction ? : Deductible
Non-Deductible
Additional cover required :  
Flood
Legal Protection
Riots, civil commotions, terror		 Eartquake
Towing
Assistance
     
Other questions ( if any ) :