Demand SFE-SAVE Quotation – International Fleet

Membre syndicat

Type of vehicle

Type of registration

VAT recovery

Vehicle make-type

Model

Fuel

Vehicle power

Kw (code P2)

HP – CV (code P1)

1st registration date

New vehicle

Insured value

New Vehicle

2nd hand vehicle

Miscellaneous

1st owner

Garage/carport

Average annual mileage

places nr(driver incl) :

Technologies

Automatic Emergency Braking :

Lane Departure Warning System :

Driver Drowsiness Detection :

Emergency call:

Adaptive cruise control :

Automated parking system:

Insurance Owner& Driver

NAME

SURNAME

Date of Birth:

Date of obtaining driving license

[text* Dateobtaineddriver'slicense]

Driver under 26 years old :

Complete Address

Street :

N° :

Box :

Zip code :

City :

Claims historic based on 5 previous year

Nbr of year without claims :

Official NCB-no claims bonus:

Claims historic :

Type of insurance desired

RC-3rd Party liability :

PJ-DAS – Legal Protection :

PC – Drive Protection :

Mini-Omnium (Fire + nature force + Glass breakage + Theft)

FULL Comprehensive (Mini omnium + Material damage) :