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Car Insurance Form

Enjoy the open road!

Take advantage of driving on the beautiful roads of France and being well insured. We offer a range of insurance covers - from third party to fully comprehensive - including breakdown assistance too.

Please complete our form below for your free quotation:

How did you find our website?
 MAIN DRIVER DETAILS
Full Name*:
 
Address:
 
Date of Birth:  
Date Driving Test Passed:  
Occupation:  
Email Address*:
 
Telephone*:
Country code:
Number:
 
Numbers of years insurance:  
Current insurance company:  
Number of years with current company:  
Current no claims bonus:  
Have you had any claims in the past 3 years?:
Type
Date
Responsibility (100%, 50%, 0%)?
 
Has an insurance company cancelled your insurance policy due to a claim, an offence or non-payment?  
     
 SECOND DRIVER DETAILS (partner/spouse)
Full Name:  
Address:  
Date of Birth:  
Date Driving Test Passed:  
Occupation:  
Email Address:  
Telephone:
Country code:
Number:
 
Numbers of years insurance:  
Current insurance company:  
Number of years with current company:  
Current no claims bonus:  
Have you had any claims in the past 3 years?:
Type
Date
Responsibility (100%, 50%, 0%)?
 
Has an insurance company cancelled your insurance policy due to a claim, an offence or non-payment?  
     
Will you be lending your car to anyone else? Or do only you and your partner drive the car?  
Would you be interested in limited kilometers per year? Please inform us of your current km on your car  
Do you use the car for private use only or also going to and from work?  
     
 CAR DETAILS
Make:  
Model and version:  
Fuel  
Capacity:  
Transmission:  
Number of Doors:  
Chassis Number(if known)  
Registration Number:  
Date of Registration:  
Date of Aquisition/Purchase:  
Is your registration plate:  
How did you purchase the car?  
Does the car have anti-theft equipment?  
Do you have a smartphone?  
Where do you park your car?  
     
 COVER
Type of cover:  
 
To complete our offer, you can also choose from one or several extra options listed below:
Mini assistance: starting from 25km away from home, replacement car 3 days accident theft or fire  
Legal assistance  
Maxi assistance: home start assistance, replacement car 3 days breakdown, 5 days accident, 15 days theft or fire  
Contents cover (€500, €1500 or €4500)  
 
     
 
 
 
     
   
     
 
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Tel: +33 (0)2 43 13 40 16

EMail: contact@exclusive-healthcare.com

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