Details of Proposer

Name
Address
Telephone

Date of Birth   Email Address Nationality NIF / Passport Occupation
Where did you hear about us * Please Select *GoogleExisting ClientRecommendationLink from another siteIntroducer4Business MagazineEuro Weekly NewsBingCyprus Local DirectoriesCyprus MailDaxi MagazineFacebookInstagramLinkedInMailshot Paphos PostPocket Diary (Cyprus)Portugal NewsRadioRock FMTwitterWe love CyprusOther

Passport Number
Passport Expiry

Over 25
Over 30

Marital Status
Resident in Cyprus

License Type

Years Licence Held

Years of NCB

Convictions Listed on Licence

Any Convictions Pending

Any Medical conditions that affect licence

Previous Insurer

Policy Number

By completing the below you are agreeing for us to contact you to discuss your insurance needs.

  We would also like to keep in touch with you about our products and services. If you would like to receive marketing information about other insurance products from us please tick the box below giving your consent. We hope that you find them useful however if you wish to withdraw your consent at any point please let us know and we will remove you from our marketing database

 

Vehicle Details

Make

Model

Registration

Engine size *Please Select* 0001-1200cc 1201-1400cc 1401-1600cc 1601-1800cc 1801-2000cc 2001-2500cc 2501-3000cc 3001-9999cc

Age of Vehicle *Please Select* 0-1 years 2-3 years 4-5 years 6-10 years 11-99 years

Location *Please Select* Larnaca Limassol Paphos Famagusta Nicosia

Body Type *Please Select* Saloon Convertible Coupe Sport

Drivers *Please Select* Insured only (Over 25) Two Named Drivers Learner Driver Any Driver (Under 25) Any Driver (25-70)

Drivers Age *Please Select* 17-21 21-23 23-25 25-70 Over 70

Experience *Please Select* 0-1 Years 1-2 Years over 2 Years

Claims and Convictions *Please Select* One or more in past 3 years Claim of 350-1700 Euros in past 3 years Claim of more than 1700 in past 3 years None

Home policy with AIG? *Please Select* Yes No

Other car insured with AIG *Please Select* Yes No

Vehicle Use *Please Select* Private Commercial

Vehicle Value

Excess *Please Select* 200 450 850 1350 and above

Fuel Type

Year of Manufacture

When Purchased

Number of Seats

Purchase Price

Country of Reg.

Where car kept during day

Where car kept at night

Towing a Trailer

Cover for car stereo/audio (over Euro 150)

Does it have ABS

Use of other vehicle

Does it have immobiliser/alarm

Modifications

 

Payment Terms

Payment Terms

 Immediate

 3 Monthly Instalments

 Credit   

 Other   

Have you any other motor insurance with American Home? If yes, please state the policy numbers

Have you a homeowners or business insurance with American Home ? If yes, please state the policy numbers

Are you now, or have you ever been insured in respect of a motor vehicle, If yes, please state the policy number and insurance company

 

Cover Required

Basic Cover

 Third Party
 Protect No Claims

 TPFT

 Comprehensive

 Comprehensive (Wide)

Insurance Period

Start Time

 

 

Details of Vehicle

Are you the registered owner of the vehicle ?
If no, please state the name of the owner.

 Yes    No

Has the vehicle been bought under a hire purchase agreement ? If yes, please state the name of the financial institution

 Yes    No

Are you the main user of the vehicle ?
If no, please state the name of the main user

 Yes    No

Is the vehicle kept at the above address when not in use ?
If no, please state the address at which its kept

 Yes    No

Is the vehicle in a good operating condition ?
If no, please explain.

 Yes    No

Has the vehicle been altered in any way from the makers standard specification ? If yes, please give details

 Yes    No

Has the vehicle been imported second hand ?
If yes, please state country of origin

 Yes    No

If the vehicle has been imported second-hand, do you intend to register it in Cyprus?

N/A

 Yes    No

 

Particulars of Other Drivers

 

Declarations

To the best of your knowledge, have you or any person who will drive the vehicle...

ever been convicted of any criminal offence in connection with any motor vehicle or violation of traffic regulations or is any prosecution pending ?

 Yes    No

I confirm all drivers are aged over 30 and under 70, have held a full UK/EU driving licence for at least 2 years, have no current convictions, and are free from claims or losses in the past 5 years

*Please Select* No Yes

During the last 3 years been penalised with penalty points inconnection with any violation of traffic regulations?

 Yes    No

Had any damage or loss claim, wether to blame or not ?

 Yes    No

Ever suffered during the last 3 years from diabetes, epilepsy, heart problems, reduced vision or hearing, or from any other disease or incapacity of the body or mind?

 Yes    No

During the last three years been driving regularly and held the appropriate licence for the specific vehicle to be insured?

 Yes    No

To the best of your knowledge, has any insurance company or any insurer at any time in connection with motor insurance for you or any person that will drive the vehicle...

Rejected any proposal for insurance ?

 Yes    No

Refused to renew or cancelled any motor policy ?

 Yes    No

Demanded increased premium or imposed special terms ?

 Yes    No

 

Category and use of the vehicle

Private Vehicle: Is it going to be used for commercial and/or business purposes?

 Yes    No

Commercial Vehicle : Is it going to transport own goods?

 Yes    No

Commercial Vehicle : Is it going to draw a trailer?

 Yes    No

Commercial Vehicle : If its a van with a passenger type body or a double cabin, is it to be used exclusively for social domestic and pleasure purposes, not for trade or business?

 Yes    No

Commercial Vehicle : Is it going to transport general cartage?

 Yes    No

Bus : Is it for private use?

 Yes    No

Bus : Is it going to transport employees of the proposer?

 Yes    No

Special Vehicle : Is it going to used for agricultural or forestery purposes?

 Yes    No

Motorcycle : Is it for private use?

 Yes    No

Motorcycle : Is it for commercial use?

 Yes    No

Motor trade vehicle : Is it going to be used for private purposes by the named drivers?

 Yes    No

Motor trade vehicle : Are they going to be driven for trial purposes by the intending purchaser accompanied by the proposer or his employee?

 Yes    No

Motor trade vehicle : Are they going to be driven for trial purposes by the intending purchaser not accompanied by the proposer or his employee?

 Yes    No