Please fill in the form completely.

Name of Proposer :
Company :
Address :
Please advise how you prefer to be contacted and the best time and day. For a return quote please advise a fax number, if available :
Tel :
Fax :
eMail :

Age (if individual) :

Business or Occupation :

Give details of all persons who to your knowledge will drive including yourself, icluding following details :
Name :
Period of Licence held continuously :
Type of Licence :
Age :
Business or Occupation :

How many vehicles to be insured/are already insured with Gulf Union?

Will the car(s) be used for :
Social, Domestic & Pleasure purposes only :
Commercial purposes :
Haulage of Goods for Reward :
Driver Instruction :
Taxi :

Particulars of Vehicle (s) :
Purchase price (BD) :
Current Value (BD) :
Date of purchase :
Year of Manufacture :
Type of Body :
Engine Size (CC) :
Regn no. or Engine No. :
Make & Model :
No. of seats including driver :
Max. Capacity (goods vehicles) :
No. of Trailers (goods vehicles) :

Tick the cover required :
Third Party only - Bronze :
Third Party, Fire & Theft - Bronze Plus :
Comprehensive - Silver :
Comprehensive - Gold :

Passengers Personal Accident Insurance :

if answer is YES :
All: Driver + Passengers :
Passengers only :

Period of insurance From :

Period of insurance To :

Can you provide a current No Claims Bonus Certificate in your name (not necessarily for this vehicle) :

If Yes, for how many years claims free driving?

Thank you for your interest in Gulf Union Insurance & Reinsurance Co. We will reply as soon as possible with the requested Insurance Quotation.

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