What is the year of construction?  * 1960  1961  1962  1963  1964  1965  1966  1967  1968  1969  1970  1971  1972  1973  1974  1975  1976  1977  1978  1979  1980  1981  1982  1983  1984  1985  1986  1987  1988  1989  1990  1991  1992  1993  1994  1995  1996  1997  1998  1999  2000  2001  2002  2003  2004  2005  2006  2007  2008  2009  2010  2011 

How much is the car currently worth (rough market value in AED)?  *

Does the car have any modifications?  *

When did you start driving this car?  *

Are you the owner and registered keeper of the car?  *  yes   no 

What do you use the car for?  *  Social only   Social and Business   Business only 

Roughly how many km does your car cover in 1 year?  *

Where is your car usually kept over night?  *  Drive   Street   Garage 

Where is your car usually kept during the day?  *  Drive   Street   Garage 

Total number of cars in your household (including this one)?  *

What is your gender?  *  male   female 

What is your marital status?  *  Single   Married   Common law/Partner   Civil Partnership   Widowed   Divorced 

How many children under 16 do you have?  *

Are you a homeowner?  *  yes   no 

What is your address  * Street, P.O. Box, City, Country

What is your Phone Number?  *

What do you do for a living? What is your job?  *

Do you have an additional job?  *  yes   no 

Have you made any car insurance claims in the last 5 years?  *  yes   no 

Have you had any driving offences in the last 5 years?  *  yes   no 

How long have you held this license?  *

How long have you held held your current driving license?  *

How many years no claims discount do you have?  *

Would you like to protect your no claims discount?  *  no   yes 

Do you have any medical conditions that affect your driving?  *  no   yes 

Have you ever been declined car insurance?  *  no   yes 

Do you drive any other car?  *  no   yes 

What voluntary excess would you like on this policy?  * 250 AED  300 AED  350 AED  400 AED  450 AED  500 AED  550 AED  600 AED  650 AED  700 AED  750 AED  800 AED  850 AED  900 AED  950 AED  1000 AED  1100 AED  1200 AED  1300 AED  1400 AED  1500 AED  1600 AED  1700 AED  1800 AED  1900 AED  2000 AED  2250 AED  2500 AED  2750 AED  3000 AED  3250 AED  3500 AED 

How would you like to pay for your car insurance?  *  Yearly   Monthly