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Motor Insurance Quote Form
Insurance Brokers, Companies and Intermediaries
Other Insurance Brokers, Insurance Companies or Insurance Intermediaries that you have approached for quotations to date
Policy Holder Details
Name
*
First
Last
Company
Business/Occupation
*
ID Number
Date of Birth
Date Format: DD slash MM slash YYYY
Email Address
*
Enter Email
Confirm Email
Contact Phone Number
*
EU Driving Licence
*
Are you in possession of an EU driving licence?
Yes
No
Details of Residency
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
*
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
Buying vehicle
Current Insurer
If you already own the vehicle, please specify its current insurer
Is the vehicle
*
Already registered in your name
First registration in Malta - Brand New
First registration in Malta - Second Hand
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
Date Format: DD slash MM slash YYYY
Young Drivers
Details of any drivers between age 18 and 24
Name
ID Number
Date of Birth
Year Licence Obtained
Edit
Delete
There are no
Drivers.
Add Driver
Maximum number of drivers reached.
Claims History
Accident/Claim History
Details and amounts of all accidents and/or claims in the past 5 years
Year of Accident
Accident Details
Edit
Delete
There are no
Accidents.
Add Accident
Maximum number of accidents reached.
No Claim Bonus
*
Amount of No Claim Bonus applicable
Insurance Company
From which Insurance Company will the No Claim Bonus be transferred?
Vehicle
From which vehicle will the No Claims Bonus be transferred?
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
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.
Insurance
Health Insurance
Home Insurance
Travel Insurance
Motor Insurance
Boat Insurance
Personal Accident Insurance
Life Insurance
Retirement Planning
Sports Medical Insurance
Get a Quote
Make a Claim
Insurance
Transit Insurance
Liability Insurance
Marine Insurance
Aviation Insurance
Property Insurance
Financial Risks Insurance
Professional Indemnity Insurance
Cyber Insurance and iGaming Exposures
Engineering Insurance
Employee Benefits
Construction Insurance
Motor Fleets & Tool of Trade
Risk Consultancy
Get a Quote
Make a Claim
Name
*
ID Number
*
Date of Birth
*
Date Format: DD slash MM slash YYYY
Year Licence Obtained
*
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Year of Accident
Accident Details
*
Accident Amount
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