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Motor Insurance Premium Quotation Request Form
Vehicle Owner Details
Name: Email Address Telephone No. Mobile No. Fax No.
Motor Vehicle Details
Please Complete the following details : 1 Insured's Name 2 Current QIC Policy No. (if any) 3 Address (Incl. P.O.Box) 4 Telephone Numbers 5 Registration No. of Vehicle (if Registered) 6 Make & Type of Vehicle 7 Year of Model 8 Chassis Number 9 Engine Number 10 C.C./ Cylinders 11 Seating Capacity of the Vehicle 12 Value of the Vehicle
Notes
1 Vehicles 4 years old and above will only be insured comprehensive 2 Under 21 years irrespective of Pricing Policy excess of Qar 1000 applicable 3 QAR 400,000, sport and Coupe cars 4 Rent a Car/Agents please contact QIC         I want to know more about Premier Cover for 2/3 years Yes No
Motor Insurance Premium Quotation
FOR QIC OFFICIAL PURPOSE ONLY
Price Quote Calculation Premium Passenger Cover Liquor Cover Off Road Cover Excess/Deductibles Others Policy Fees TOTAL PREMIUM
QIC Contact Details
email: onestop@qic.com.qa Fax: +974 4831569		Quote valid for 3 Days when signed and stamped (not applicable for email quotes)