Anjo Insurances
Motor Insurance Quote
Application Form

Please provide the following contact information:

THE PROPOSER
A) Name
B) Title
C) Postal Address
D) Work Phone
E) Home Phone
F) E-mail
G) Date of Birth
H) Driving License Number
VEHICLE PARTICULARS
A) Make
B) Type of Body
C) H.P. or C.C.
D) Year of Manufacture
E) Price Paid (Comprehensive Only)
F) Left or Right Hand Drive	Right Left
SELECT YOUR COVER:
A) Comprehensive or Third Party	Comprehensive Third Party
USE OF VEHICLE:
A) Will the vehicle be used only for private purposes or traveling to and from your business (but not used during the course of your business)	Yes No
B) Will the vehicle be used during the course of your business or employment for commercial traveling or the carriage of goods and samples for business purposes?	Yes No
C) Number of Drivers	1 2 3 4 5 6 7 8 9 10
CONDITION OF VEHICLE
A) Good State of repair?	Yes No
B) Has engine been modified to increase performance?	Yes No
C) Are spare parts stocked locally?	Yes No
D) Has the vehicle been involved in any accident or was a write off?	Yes No
FITNESS
Have you or any other person who may drive:
A) Suffer from defective vision, hearing or any other disabilities?
DETAILS OF THE DRIVERS (other than the named insured)
Driver 1
Name
Address
Occupation
Date of Birth
Driver's License Details (Date Issued, Expiration Date & Number)
Driver 2
Name
Address
Occupation
Date of Birth
Driver's License Details (Date Issued, Expiration Date & Number)
Driver 3
Name
Address
Occupation
Date of Birth
Driver's License Details (Date Issued, Expiration Date & Number)
Driver 4
Name
Address
Occupation
Date of Birth
Driver's License Details (Date Issued, Expiration Date & Number)
Driver 5
Name
Address
Occupation
Date of Birth
Driver's License Details (Date Issued, Expiration Date & Number)
CLAIMS EXPERIENCE OF DRIVERS:
List any accidents or losses suffered in the past 60 calendar months in connection with any motor vehicle owned or driven by you or any listed drivers