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Motor Insurance Quotation Form

Taking out motor insurance with Culpeck Insurance Broker means that you will hold cover with a long- established, very professional English/ German speaking company with the highest standard of insurance cover on today's BFG/ NATO market.

All of our motor insurance policies come with unlimited mileage, unrestricted overnight parking, roadside- assistance, business cover, variable excesses, flexible payment methods, payment- freeze but cover guarantee (e.g. if on Operational Tour), and most importantly an easy stress-free claim procedure with swift settlement (hire car included).

Worried about when you leave Germany? No need! We have no kind of cancellation fee, your refund will be calculated by the day - not by the month - and your No Claims Discount certificate will be in English, where necessary we will even confirm your entitlement to your new company over the phone no matter where in the world.

*** OUR SUPERDEAL ***

You are already insured with Culpeck or wish to insure an additional vehicle along with your first car?
If so, please simply check the 'SUPERDEAL' box at the end of this form and we will soon find out if you qualify for our special
SECOND & THIRD CAR DISCOUNTS.

Enjoy the privilege of insuring up to 3 cars on 1 set of No Claims Discount & give your bank balance a break.

Personal Details
Salutation: Mr. Mrs. Miss. Ms. Dr.
BFPO/ Unit address:	Postal address:*(n/a if same as unit)
Telephone number:*
Fax number:*
Email address:
Age:	22 23 24 25 26 27 28 29 30 31 32 33 34 35+
Nationality:	Albania Belgium Bulgaria Canada Croatia Czech Republic Denmark Estonia France Germany Greece Hungary Iceland Italy Latvia Lithuania Luxembourg Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Turkey United Kingdom United States 'OTHER'
Married, engaged or do you have a life- partner?	Yes No
No Claims Discount entitlement:	--- Please select --- License less than 3 yrs License more than 3 yrs 1 year 2 years 3 years 4 years 5 years 5 years/ protected 6 years 6 years/ protected 7 years 7 years/ protected 8 years 8 years/ protected 9 years 9 years/ protected 10 years and more... 10years+/ protected
Vehicle Details
Make:
Model:
Type of chassis:	--- Please select --- 2 dr convertible 2 dr coupe 3 dr hatchback 4 dr saloon 5 dr hatchback Estate Jeep/ 4WD Minibus (7 seater) Other
Cubic Capacity:		Diesel
kW*/ bhp*	/
First year of registration:	--- Please select --- brand new 2010 2009 2008 2007 2006 2005 2004 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 before 1985
Value:	--- Please select --- 0 - 4,999 USD 5,000 - 9,999 USD 10,000 - 14,999 USD 15,000 - 19,999 USD 20,000 - 24,999 USD 25,000 - 29,999 USD 30,000 - 34,999 USD 35,000 - 39,999 USD 40,000 - 44,999 USD 45,000 - 49,999 USD more than 50,000 USD
Cover Required
Driver(s):	--- Please select --- Insured only Insured & Spouse Open Driver
Type of insurance cover: [ ? ]
Excess(es) in € [ ? ]	--- Please select ---
Traffic Legal Insurance* [ ? ]	yes no
Personal Accident Insurance* [ ? ]	yes no
I am not a client of Culpeck Insurance Broker...
...but I am seeking new insurance*
...as my policy is due for renewal*
For Culpeck clients only
I have purchased a second/ third vehicle and would appreciate a 'SUPERDEAL'
I wish to change my vehicle*
My policy is due for renewal/ I would like Culpeck to check my premium*
*optional
Remarks/ Additional information
Is this form understandable and easy to complete?	Yes Yes, but still room for improvement NO!!!
You need other than motor insurance? Please be so kind to contact one of our offices. Thank you!