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IBEX MOTOR INSURANCE APPLICATION Please fill all required areas of the form. You will receive your quote within short time. PROPOSER´S NAME AND SURNAME * Date of Birth (dd/mm/yyyy) * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 Country of risk * Spain Gibralter Portugal Your email address * Repeat your email address * Contact telephone number * DRIVER DETAILS Please fill all required areas of the form. You will receive your quote within short time. Has any person who may drive the vehicle been disqualified from driving in the past 10 years? * yes no Does any person who may drive the vehicle currently suffer from, or suffered from in the past any disability or medical condition whether or not it may impair their ability to drive? * No Yes If you have answered YES to any of the above questions please give further details: VEHICLE DETAILS Please fill all required areas of the form. You will receive your quote within short time. Make * Please enter the first character of the model * Type of Vehicle * Engine Size * Year Of Make * Fuel Type * Petro; Diesel Present value of vehicle (€) * Number of Km/Year? * 0-5000 5-15000 15-30000 30-45000 45000+ Is the vehicle a Cabrio/Soft Top? * yes no Has the vehicle been imported from outside the EU? * yes no Exact Model * Country of Registration * Vehicle Registration Number * Does the vehicle have temporary/tourist plates? * Is the vehicle an ambassador's car? * Does the vehicle have more than 7 seats? * Yes No Are you or your legally married spouse the owner and/or registered keeper of the vehicle? * yes no START OF COVER Please fill all required areas of the form. You will receive your quote within short time. Please state when you would like the cover to begin (dd/mm/yyyy) * COVER DETAILS Please select type of cover you require. Type of cover required? * Third Party Only Fully Comprehensive Is Legal and Breakdown Assistance to be included? * Yes No Is Hire Car Cover to be to be included? * Yes No How many years no claims discount are you claiming? * 1 2 3 4 Years or More Will you tow a trailer/caravan not excceding 750kg in total? * Yes No Will the vehicle be taken outside the Iberian peninsula for more than 90 days, or for more than 90 days in total witin the period of insurance? * Yes No Will the vehicle be taken outside the EU at anytime? * Yes No MODIFICATION DETAILS AND VEHICLE SECURITY Please select type of cover you require. Has the car been fitted with any optional extras/modifications since manufacture? iF YES, PLEASE STATE WHAT? Is the vehicle fitted with an alarm? * Yes No Is the vehicle fitted with an immobiliser? * Yes No Parking location * Current Insurer (If none then state "NONE") * ACCIDENT DETAILS Please select type of cover you require. Please add any accidents, losses or claims any driver to be insured has had during the last three years (regardless of blame) and whether they were reported to the insurer or not(If none pleas write NONE) * Please add any motoring offence convictions that any driver to be insured has had in the last five years (including fixed penalty notices) If Nome please write NONE *