Agence Limonier Insurance & Banking in France since 1992

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Main Driver

Name *
Full Address *
Contact Number *
E-mail address *
Occupation
Usage
Date of Birth *
Date of Driving Licence *
No Claims Bonus (in years)
Claims last three years?

Other Drivers

Name
Licence less than 3 years?

The Car

Make
Model
Version
Petrol / Diesel
Registration number
Date of first registration
Where is the car parked at night?
Will you drive less than 8 000 KM (5 500 Miles) per year?

Insurance Cover

Type of Cover

Additional Information

Your Comments

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