INSURANCE ESTIMATE FORM

Solicitation Policy    Privacy Policy

APPLICANT’S DETAILS

Contact Name *

E-Mail *

Phone Number

DRIVER’S DETAILS

Date of Birth of main driver *

Gender of main driver

Male          Female         

Number of claims of accidents for last year *

0  
1  
2  
3  
More Than 3

Color of main driver’s Japanese Driver’s License *

Green   Blue   Gold

Age of youngest driver in the home *

Home Address of main driver

Address 1

Address 2

Prefecture

City

DETAILS OF THE VEHICLE TO BE INSURED

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*

Vehicle Manufacturer

Vehicle Model

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?

Yes          No         

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 *

Leisure Commuting Business

DETAILS OF THE VEHICLE TO BE INSURED

Do you have auto insurance currently? *

Yes          No         

Non-fleet rating

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.

Other comments or questions

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