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Classic Car Proposal Form
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1. Name
*
First
Last
2. Email
*
3. Mobile Number
*
4. Occupation
5. Policy Start Date
6. Classic Car Make and Model
7. Model Year
8. Chassis Number
9. Current Mileage
10. Car Value (as per Last Policy)
11. Location of your classic car - Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
12. Regarding ownership of the car; please tick if any of the below is applicable.
The car not leased, or subject to a loan, rental or hire purchase agreement or other encumbrance
The car is owned by me only and is registered in my name.
13. Please tick the applicable security measures to prevent theft of your car from the below.
Car is kept in a building of good condition.
Car is not used for any business or professional purposes.
Car is not left unattended by day or night.
Parking location is not shared with any other party.
Car is fitted with a burglar alarm.
There is closed circuit television in the parking location.
Car is fitted with immobilisers.
Access to the parking location is controlled
Car is not kept in any other locations
14. Please tick the applicable security measures to prevent fire damage to your car from the below.
Parking location has Fire extinguishers
Parking location has fire alarm connected to a fire station
Parking location has smoke detectors.
Parking location has spriklers.
15. Upload the front side and back side of UAE driving license of the main driver
Click or drag files to this area to upload.
You can upload up to 2 files.
16. Upload the front side and back side of UAE driving license of the second driver
Click or drag files to this area to upload.
You can upload up to 2 files.
17. Upload the front side and back side of UAE driving license of the third driver
Click or drag files to this area to upload.
You can upload up to 2 files.
18. Upload the front side and back side of Mulkiya (Vehicle registration card) of your car
Click or drag files to this area to upload.
You can upload up to 2 files.
19. Have you or any of the named drivers, during the past three years been subject to a driving disqualification or been convicted during that period of any offence in connection with any vehicle, or is any prosecution pending?
Yes
No
20. If 'yes' to the above, please give details.
21. Have you or any of the named drivers during the last three years had any accident, loss or damage involving a vehicle?
Yes
No
22. If 'yes' to the above, please give details.
Declaration - I/We declare that (a) the information disclosed on this proposal has been completed after proper enquiry; (b) its contents are true, accurate and complete and (c) reasonable care has been taken to answer all questions honestly and to the best of my/our knowledge. I/We understand that the signing of this proposal does not bind me/us to complete the insurance but agree, should a contract be concluded, this proposal, the statements made in it and the information provided in connection with it will be relied upon by RAKINSURANCE in deciding whether to accept this insurance.
I agree
Submit