Thames Insurance Group

ONLINE INSURANCE
Thames Insurance Group
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Please complete details below:

Your Details

Title

Name:

Last Name:

Date of Birth

Address

Post Code

E-mail:

Phone:

Fax

Employment status

Do you own another vehicle

If Yes, please specify the model

Has this driver made a claim in the last 5 years?

Date of Claim

Claim amount (USD)

Claim Description

Your Vehicle

Year of make

Make

Model

Value of car

Current Mileage

Annual Mileage

Where the car is kept at nights

Security device fitted

Have any modifications made or accessories fitted to the car?

Use of vehicle (Use for the policyholder's business)

Registered keeper

Vehicle ownership

Type of Business

Your Cover

Start Date (dd/mm/yy)

Preferred payment method

Third Party Liability (TPL)

Third Party Liability (Limit)

Physical (accidental) damage (PD)

Do You require coverage for the Azerbaijan?

Other information

How did You hear us?

Other wishes

LEGAL IMPORTANT - The answers you have given to these questions will usually provide us with sufficient information to enable us to consider this proposal. However, because no list of questions can be exhaustive please consider carefully whether there is any other information known to you which could influence our acceptance and assessment of the risk. Material information would include any special feature of the vehicle, use, driver's history or its location which makes losses more likely to happen or more serious if they do.
I declare that to the best of my knowledge and belief the answers given are true and all material information as explained has been disclosed. Your quotation will be based on the information you have provided above and this information will form the basis of your policy if you decide to buy, please check the information you have entered.

IMPORTANT NOTE: You should receive Your quotation to Your E-Mail address within 24 hours. If You do not, please contact us again.