TIS: Car Insurance - On-line Application/Quotation Form

Full Name
NIE Nº.
Email
Tel./Mob. Number(s)
Address (Spanish)
Post Code
Gender
Marital Status
Date of Birth Date of Birth / DD / MM YYYY
Date of Driving License Date of Driving License / DD / MM YYYY
Profession
Make & Model of vehicle
Engine Size
Engine Power (KW)

As per Ficha tecnica - Potencia
Registration Plate e.g. 1234YXZ
Date first Registered Date first Registered / DD / MM YYYY
Nº of Doors
Nº of Seats
Fuel Type
Use of Vehicle
Insurance Cover required
Drivers to be covered

Drivers to be covered All drivers over 25 To include younger drivers Named Drivers only
Details of Named or Young drivers
Full name, date of birth, NIE and No Claims Discount entitlement
Payment Method

Payment Method Cash Debit/Credit Card Direct Debit
IBAN CODE : 24 Characters.
ESxx , plus Bank Account Nº ( 20 Digits 4-4-2-10 )

Policy MUST be paid by Direct Debit to qualify for CashBack and other offers.
Any Comments , Suggestions or Recommendations :
Start Date of Policy - if known Start Date of Policy - if known / DD / MM YYYY
Data Protection/Ley de Protección de Datos

Data Protection/Ley de Protección de Datos I agree to the sending and retention of this personal data in compliance with The Data Protection Act. / Estoy de acuerdo con el envío y la retención de estos datos personales de acuerdo con la Ley de Protección de Datos.
Type the letters you see in the image below.