TIS: E.Scooter Insurance - On-line Application/Quotation

Owner's Full Name
NIE Nº.
Date of Birth
Email
Tel./Mob. Number(s)
Address
Post Code
E-Scooter Registration Number e.g. 1234 NPT
Public Liability
(Automatically included on all policies)

Public Liability (Automatically included on all policies) 80€ p.a. - 6,450,000€ Standard Liability 90€ p.a. - 6,450,000€ Standard Liability + 10,000€ Driver Medical (+10€) 95€ p.a. - 6,450,000€ Standard Liability + 300,000€ Extra Liability(+15€) 105€ p.a. - 6,450,000€ Standard Liability + 300,000€ Extra Liability(+15€) + 10,000€ Driver Medical (+10€)
IBAN CODE : 24 Characters.
e.g. ES07 1234-1234-1234-1234-1234

Policy MUST be paid by Direct Debit
Any Comments, Questions or Suggestions :
Required Start Date of Policy (can be date of application) Required Start Date of Policy
(can be date of application) / 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.