Motor Insurance – Assessment of Demands and Needs

Insurance Brokers, Companies and Intermediaries

Other Insurance Brokers, Insurance Companies or Insurance Intermediaries that you have approached for quotations to date

Are you an existing MIB Customer?*

Yes
No

Please specify your Customer Number

Which Office would you prefer to use?*

Head Office (Qormi)
Gozo branch

Policy Holder Details

Name*

First Last

Company

Business/Occupation*

ID Number

Date of Birth

Email Address*

Enter Email Confirm Email

Contact Phone Number*

EU Driving Licence*

Are you in possession of an EU driving licence?

Yes
No

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Details of Residency

Postal Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Residency Duration*

Have you resided in Malta for at least 2 years?

Yes
No

Insurance Refusal*

Have you been refused insurance by any other company

Yes
No

Insurance Refusal Details

Details of Insurance Refusal

Age of Driver*

Vehicle Details

Number Plate*

Make and Model*

Year of Make*

Engine Capacity*

Break Horse Power (BHP)

KW of Engine Power

If Electric or Hybrid

Colour of Vehicle

Estimated Vehicle Value*

Do you intend to drive overseas with this vehicle for more than 30 days within one period of insurance?*

Yes
No

Road Asistance*

Do you require Roadside Assistance?

Yes
No

Insurance Cover*

Comprehensive
Third Party Fire and Theft
Third Party Only

Vehicle Owner*

Do you already own this vehicle or are you buying the vehicle?

Already own vehicle and its registered in your name
Buying Vehicle

Current Insurer

If you already own the vehicle, please specify its current insurer

If Buying Vehicle for the first time

Brand New - First registration in Malta
Second Hand - First registration in Malta
Second Hand - Already registered in Malta
Red Plates Registration (Weekends and Public Holidays)
Classic Car Registration (Black Number Plates)

Is the car financed though a loan?*

No
Yes

Is the vehicle a convertible?*

No
Yes, hard top
Yes, soft top

Limitations as to Use of Vehicle*

Private and Pleasure purposes
Commercial Use (Carriage of Goods)
Use for Hire and Reward (please specify)

Hire and Reward use

Additional Drivers

Drivers

Insured only driving (applicable for over 25 years)
Two named drivers over 25 years
Any driver aged 25 years
Any driver over 25 years and named drivers under 25 years (details of young drivers to be inserted below)
Policy holder under 25 years and any driver over 25 years

Name of 2nd Driver

First Last

ID Number of 2nd Driver

Date of Birth of 2nd Driver

Young Drivers

Details of any drivers between age 18 and 24

Name	ID Number	Date of Birth	Year Licence Obtained	Actions

There are no Drivers.

Claims History

Accident/Claim History

Have you or any other driver had any accident whether claimed or not, or suffered any damage including fire, malicious damage or theft claims involving any motor vehicle in the past 5 years?

Year of Accident	Accident Details	Actions

There are no Accidents.

No Claim Discount (NCD)*

0 Years - Don't have No Claim Discount
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years - Maximum NCD or over

Please give some information why you don't have No Claim Discount to use on this vehicle*

Insurance Company

From which Insurance Company will the No Claim Discount be transferred?

Vehicle

Number Plate of vehicle from which the No Claim Discount will be transfered.

Additional Details

Health Impediments

Do you have any health impediments we should be aware of?

Additional Policies

Details of any other insurance policies that you may consider transferring and placing though us

Additional Comments

Attach any relevant documents.

Drop files here or

Max. file size: 5 MB.

Terms Accept*

I have read and accept MIB's Client Terms of Business & Privacy Policy.*

I understand that by completing this form the data will be processed by MIB in line with GDPR and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purposes of providing your insurance services.

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties direct or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB and the providers of insurance and ancillary services.

Motor Insurance – Assessment of Demands and Needs

Policy Holder Details

Vehicle Details

Additional Drivers

Claims History

Additional Details

Support

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