Section 1 – Owner Details:

First Name: Last Name: Date of Birth: Age: Gender: Marital Status: Address: Zip Code: City: State:

Section 2 - Cover Required: (Comprehensive Cover only)

Car Estimated Value (USD): (according to market value or 20% less than last year's insured value)

Section 3 - Vehicle details:

Make: License Plate: Model: Year of Manufacture: Model description:

Section 4 – Other Details (if applicable): for each insurance type tick one box only

Do you have Travel Insurance with us? Do you have Home Insurance with us?

Section 5 - Insurance Premium Payment/Other Charges Instructions:

I hereby authorize Just Finance to collect the premium/other charges by :

1. Debiting my Bank A/C. No: or

2. Charging my Credit Card No: Valid Thru: Declaration

I/We declare that the details given in this application form are correct. I/We understand that any instructions sent to Just Finance via fax shall be considered valid and binding and may be acted upon. Just Finance may use copies of the fax transmissions in a court of law. Disclaimer All insurance is subject to the Bank's and/or Insurance Company's approval at prevailing terms and conditions. Customer’s Signature: Date: Customer Services Manager’s Signature: © Just Finance Insurance Company, New York, NY.

  Car Insurance Application Form