Agency Allianz - Franck Haloche

Agency Allianz - Franck Haloche

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Call now for a FREE quote on: 033 (0)2 43 05 21 82

Car insuranceCar Insurance Form

To receive a quotation for Car Insurance, please fill in the following details and click SEND. We will then respond to you as soon as possible.

Please note: We cannot offer you a short term/temporary insurance. We can only insure your English registered car if you are going to reregister your car in France in the following three months.

     

MAIN DRIVER(S)

   
Full Name:
 
Address in France  
Address in UK(if any)  
Date of Birth: dd/mm/yyyy
 
Occupation:  
Date Driving Test Passed: dd/mm/yyyy  
Any other driver:
(date of birth + date driving test passed)
 
Telephone:
 
Email Address:
 
Do you have a smartphone?  
     

CAR

   
Make:  
Model:  
Fuel  
Capacity:  
Transmission:  
Number of Doors:  
Chassis Number(if known)  
Date of First Registration: dd/mm/yyyy  
Date of Aquisition/Purchase: dd/mm/yyyy  
Registration Number:  
Is Car Locked in Garage Overnight?  
Bought with 'cash' or load?  
     

CURRENT NO CLAIM DISCOUNT

 
Number of Years Insured:
(in France or in UK) bonus-malus
 
Any claim in last 3 years?  
Current or Previous Insurer:  
How many years with same company?  
     

USE OF THE CAR

 
Private use only:  
Private use & commute to work:  
Would you consider limiting your mileage to?  
     

INSURANCE COVER

 
Type of cover:  

ADDITIONAL COVER

 
Contents (in the car)?  
Home Start (roadside rescue)?  
Within Europe as well?  
Replacement Car?  
     
How did you hear about us?  
Discount Code:  
Quotation in French only?  
     
 
 
Please call us on 0033 (0)2 43 05 21 82 if you have any problem with this form
     
   
     

 

Agency Allianz - Franck Haloche

1 rue Louis Blériot
Parc d’activités des Sémondières
53500 ERNEE
France


© COPYRIGHT ALLIANZ FRANCK HALOCHE 2017

Tel: 0033 (0)2 43 05 21 82
EMail: 4005417@agents.allianz.fr