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Insurance company
Insurance company*

Insurance holder data*

Phone number
Delivery address
Address
Surname
Name
Purpose of operation*

The main place of exploitation*

Vehicle mileage*
Authorized owners*

Start of insurance policy*
 
Insurance policy period (months)*
Please, attach copies of required documents (jpg, gif, png)
Vehicle registration certificate*
Copies of passports of the insured and the authorized person*
Driving license of insured and authorized holders*
Copy of the certificate of state registration, if the insured person is legal