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Contact Name *
Date of Birth of main driver *
Gender of main driver
Number of claims of accidents for last year *
Color of main driver’s Japanese Driver’s License *
Age of youngest driver in the home *
Home Address of main driver
The official classification of the vehicle can be found on its shakken document. Please refer to that document for the notated portions of this section
Type of vehicle is labeled“型式 /katashiki“ on your shakken document
Type of Vehicle*
Year of Vehicle
Vehicle's estimated current market value (JPY)
Date of initial registration is labeled “初度登録 / shodotouroku“ on your shakken document *
Date of Initial registration
Is the vehicle modified from the original stock condition?
Vehicle’s primary purpose
If the vehicle is used more than 15 days per month for commuting or business it is classified as a commuting or business vehicle.
Vehicles main purpose *
Do you have auto insurance currently? *
Details of the main driver’s non-fleet rating can be found in the current insurance policy document. If the non-fleet rating is not known, or you are a recent arrival to Japan, please select 6.
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