Motor Insurance Application Form

Assured*:

Mortgage:

Address*:

Telephone*:
Fax:
E-mail:
Period of insurance from*:
Period of insurance to*:

Motor Description

Make*:
Model*:
Eng.No*:
H.P*:
Use*:

       Private     Commercial
Chassis*:
Seating/capacity*:
Value US$*:
Plate No*:
Cover Conditions

T P L

Total loss 

Pass + DR

Full liablity

All Risk
Road Ass

Mode of Payment: 

* Cash
* Bills ( BK Audi), ITN account    : 

US  $  191706 461 002 007 01
LBP 191706 461 001 007 02
* Credit Cards :  
  Expiry date : 

For delivery please provide full address
Applicant Name*:
Approval*:

 

 

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