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	Motor Insurance
	Home Insurance
	Health Insurance
	Travel Insurance
	Personal Accident
	Yachts & Pleasure Craft Insurance
	Business Insurance
	Professional Indemnity Insurance

To obtain a quote, please provide the following details:

Your Details

Title (Mr/Ms/Dr)
First Name		Last Name
I.D. Card number		I.D. Card number of your spouse/partner
Address		Telephone
Fax		Email address

Address of the property to be insured (if different from above)

Have you or any members of your family usually residing with you suffered any loss, damage or liability from any cause within the past five years?

Yes No

If Yes, have these been claimed under a policy of insurance?

Yes No

Are your premises protected by an alarm and subject to an annual maintenance contract?

Yes No

Buildings

What is the Buildings Sum Insured based on rebuilding cost as new?

€

Is the property left unoccupied for more than 90 consecutive days?

Yes No

Contents

Replacement value as new of all your contents

€

Do you require Full Theft cover?

Yes No

All Risks

Please tick the appropriate box if cover is required. Cover is only available if contents are to be insured. The Sums Insured should represent the full replacement value of the property to be covered.

Unspecified Items

Articles of personal use, worn or carried, (including gold and silver items, jewellery, watches), photographic equipment, binoculars, telescopes, furs and sports equipment, inside or outside the home. Excluding camping equipment, contact lenses, dentures, telephones, pedal cycles, money, vehicles, tools, water craft, aircraft and musical instruments

Unspecified Items

€698.81 Lm 300

Specified Items

Item	Value €
	€
	€
	€
	€

Total value of items:	€

Note: Evidence of value is required for individual articles over EUR 174.70 LM 75
Geographical Area: Maltese Islands

Family Public Liability

Please complete this section only if you require the liability section to be extended
to Family Public Liability.
Please indicate the number of members in your household.

Additional Covers

Please tick the appropriate box if cover is required.

	Sports Equipment (Maximum Sun Insured €465.87* Lm200)*
	Pedal Cycles, Specify Sum Insured: €
	Freezer Contents (Maximum Sum Insured: €698.81* Lm300)*
	Personal Accident (Sum Insured: €11,646.87* Lm5,000 per member)*
	Legal Expenses (Maximum Sum Insured: €582.34;* Lm250 / €2,329.37 Lm1,000)*
	Accidental Damage on Buildings
	Present and Gifts (Maximum Sum Insured: 10% of sum insured on Contents or €11,646.87 Lm5,000)

Do you have other policies with Middlesea insurance?

Yes No

If YES please give Policy Number(s)

Are you a shareholder of Middlesea Insurance p.l.c.?

Yes No

How would you like to receive your quotation?

	E-mail
	Fax
	Post

I/we acknowledge that Middlesea Insurance p.l.c. (MSI) may process the personal data that I/we provide in accordance with the Data Protection Act (Cap 440) and with the Data Protection Policy of the Company.

I/we acknowledge that I/we have a right to request to and rectification of such data as processed by MSI. Any such request must further be signed by myself as the applicant/joint assured/joint holder to whom the personal data relates.

We would like to keep you updated with our latest products & services. Your details will not be passed on to any third parties.

If you do not want to receive this information please tick this box

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	Middlesea Insurance p.l.c. Middle Sea House Floriana, FRN1442 Malta

	Tel: (+356) 21246262 Fax: (+356) 21248195

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Middlesea Insurance p.l.c. is a company authorised under the Insurance Business Act, 1998 to carry on both Long Term and General Business and is regulated by the Malta Financial Services Authority.Registration Number: C5553.

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