Offer Form - A.M.A. Pacific Insurance Agents Ltd

Insurance Type *

Property Insurance

Property Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Year Of Construction *

Private Swimming Pool *

Yes
No

Covered Area In m2 *

Number of Floors *

Number of Bedrooms *

Construction of Walls *

Construction of the Roof *

Self contained having its own separate lockable front door? *

Yes
No

Occupied solely by you as a permanent residence? *

Yes
No

In a good condition of repair and will be maintained? *

Yes
No

How long is the property unoccupied? *

Value of contents *

List any items worth more than 5% of the total sum of content's value *

Motor Insurance

Vehicle Type *

Registration Number *

Country of Issue of Driving Licence *

Driving Experience (Years) *

Driving history in Cyprus ( if yes provide no claim certificate) *

Yes
No

Type of Coverage *

Upload copy of passport *

Click or drag a file to this area to upload.

Upload copy of driver's license *

Click or drag a file to this area to upload.

Upload registration certificate (Log Book) *

Click or drag a file to this area to upload.

Addition Driver Insured ? *

Yes
No

Additional Driver Information

Additional Driver Name *

Driver's Age *

Driving Experience (Years) *

Any accident the last 3 years (if yes then provide a summary description) *

Medical Insurance

Insurance cover *

Sum of cover: *

Details of main insured:

Full name *

Identification number / Passport no *

Nationality *

Date of birth *

Address of residence *

Email *

Phone Number *

Mobile Number *

Details of children insured

Full Name

Identification number / Passport no

Date of birth

General Information

Do you stay abroad for the period of more than two (2) consecutive months in a year? *

Yes
No

Are you involved in any sport or activity of at an amateur or professional level? *

Yes
No

Do you have any personal Accident or Medical insurance in force? *

Yes
No

Is this insurance policy intended to replace any other Medical insurance and or any other accident insurance? *

Yes
No

Has any insurance company at any time and in connection with Personal Accident Insurance and /or Medical insurance postponed modified or rejected, postponed, modified, or suspended a proposal made by you or by any of the dependents or refused to renew or cancelled any personal accident insurance or medical insurance? *

Yes
No

When you or any of the dependents were the last time and for what reason consulted a medical practitioner? Please provide full name and address if any. *

Yes
No

Travel

Trip Type *

Annual multi trip
Single trip

Country of Residence *

Destination *

Who is travelling in your party? *

Main Adult Age *

Departure *

If it is an annual multi-trip, how long will you be in each trip? *

Yacht Insurance

Yacht Name *

Model *

Date Purchased *

Year Build *

Material of Hull *

Registration Number *

Price Paid *

Dimensions *

Length *

Is the vessel conversion? *

Yes
No

Is the vessel amateur Built? *

Yes
No

Is any liquid gas plant installed? *

Yes
No

Is the vessel fitted with remote control or automatic fire extinguishers in the engine room and the tank space? *

Yes
No

What other types of fire extinguishing equipment are carried on board? *

Has the maintenance of the fire extinguishing systems been carried out as per manufacturer’s instructions? *

Yes
No

When the vessel was last surveyed by a qualified surveyor ? *

When the vessel was last went through an out of water maintenance? *

Please provide copies of all surveys and repairs performed *

Click or drag a file to this area to upload.

Engine Serial Number *

Name of Manufacturer *

HP *

Will the vessel be used for pleasure purposes only? *

Yes
No

Will the vessel be used for commercial purposes? *

Yes
No

Will the vessel be used for racing? *

Yes
No

What cruising area is to be covered? *

Where is the vessel laid up when in commission? *

Where is the vessel laid up during winter period? *

Period of vessel’s usage: in commission *

Period of vessel’s usage in the sea *

Marine Cargo Insurance

Sum Insured *

Subject Matter Insured *

Value *

Vessel name *

Voyage from: *

Voyage to: *

Departure date *

Arrival date *

Depart port *

Arrival port *

Container number *

Shop Insurance

Full description of the activity of the store *

Store Address *

How long practiced this activity period of insurance ? From *

How long practiced this activity period of insurance ? Until *

Part 1 - Fire & Special perils

Amount Insured for Building (€) *

Amount Insured for content (€) *

Amount Insured for merchandise (€) *

Amount insured for machinery and equipment (€) *

Amount insured for furniture (€) *

Amount Insured for Decoration and improvements (€) *

Dates

Burglury *

Loss of Profits *