Motor Insurance Application Form

Motor Insurance Application Form

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Motor Insurance Application Form

APPLICATION FORM

Motor Insurance

1. Please provide the following contact information:
First Name
Last Name
Street Address
Address (cont.)
City
Zip/Postal Code
Phone
E-mail

2. Insured Vehicle:
Sedan		Pick up truck (private)
	Brand
	Model
	Year
	License
	Transmission (gear)	Automatic Manual
	Engine	CC
	Seats
	Sum Insured (market value)	Baht

3. Type of insurance selected
	Comprehensive & Compulsory Third Party Liability only & Compulsory

4. Premium Baht

(including VAT & Stamp Duty)

5. Your existing insurance details:
Expiry date:	-- mm/dd/yy
Insurance Company:

To send this form by fax, print this form and fill in the form, thank you.
Proposer's Signature	...................................................................
Date	...................................................................

ICC Tel: 679-8184-91, 679-8689-90 Fax: 285-6427-8		Home
Revised: 11/03/00