Allcare Insurance Agency Ltd University Roundabout
Msida MSD 1751 Malta

Tel: (356) 21 330011
Fax: (356) 21 347947/8

 
 

MOTOR INSURANCE QUOTATION FORM

Name
*
Address
 
Postcode
 
Tel. No. / Mobile No.
*
Fax. No.
 
E-mail Address
*
Vehicle Make & Model (eg Kia Avella, etc.)
 
Engine c.c./H.P.
 
Year of Manufacture
 
Current market value of vehicle
 
Are you a Middlesea Insurance shareholder ?
 
If yes, state number of shares
 

Type of cover required ( You may ask for a quote on more than one type of cover ):
Comprehensive Third Party Fire & Theft Third Party Only

Who will drive the vehicle?
The Insured only
If Yes, Please state Age of Insured
 
The Insured & Spouse
If Yes, Please state Age of Spouse
 
The Insured & One Named Driver
If Yes, Please state Age of Named Driver
 
Any Driver
Aged 25 Years & Over
Aged 21 Years & Over
Aged 18 Years & Over
 
Would you like to protect your No Claims Discount in the event of a claim ?
Yes
No
 
Do you hold any other policies with Middlesea Insurance Company plc  or with Citadel Insurance plc?
Yes
No
 
Number of years of No Claims Bonus which you can apply to this car :

Name of insurance company you are currently insured with

Have you or any person who will drive had any accident losses or damages (whether covered by Insurance or not) within these last four years?
Yes
No
(If yes please provide details):

DATA PROTECTION

Insofar as the information that you provide us with in this form constitutes personal data for the purposes of the Data Protection Act 2001, Allcare Insurance Agency Limited will only process this information in the manner and for the purposes laid down in its Privacy Policy. By completing this form and clicking on the ‘Submit’ button below, you consent to Allcare Insurance Agency Limited processing this information in accordance with this Policy. Please view our Privacy Policy before submitting this form.