Motor Insurance - Middlesea Insurance Malta

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quote motor insurance
To obtain a quote, please provide the following details:

Your Details


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

Your Vehicle


Vehicle make	e.g. Opel
Vehicle model	e.g. Astra Club
Year of manufacture
Type of body
Engine capacity

Estimate of current value of vehicle, including accessories and spare parts:

How many years ‘No Claims Discount’ are you entitled to?

years

Who is/are the authorised driver/s?

One person driving (25 yrs & more)

Specify Driver:

You and one named person (25 yrs & more)

Specify Driver:

	aged 21 years and over
	aged 25 years and over

Have any accidents, losses or damages been claimed from your past/current insurer?

Yes No

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

Yes No

Please tick the type of cover required:

  Third Party Only
  Third Party, Fire and Theft
  Comprehensive

If a Comprehensive policy is required do you wish to:

	opt for the Protected No Claims Discount
	opt for replacement vehicle extension?
	opt for the earthquake extension?
	increase medical expenses cover? (Third Party, Fire and Theft only)
	increase the limit for loss of use (Your Liability towards Third Parties)
	increase voluntary excess by €116.47 (Lm50) (Maximum Discount: €116.47 Lm50)
	increase voluntary excess by €232.94 (Lm100) (Maximum Discount: €232.94 Lm100)

Do you have other current motor or home policies with Middlesea Insurance p.l.c.?

Yes No

If YES please give Policy Number(s)

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

Yes No

If YES, please quote your MSE A/C 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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