Personal Information
Vehicle Information
Coverage & Submit
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I understand that this insurance is not intended for rental cars, nor for covering my (US) car for holidays / vacation in Germany.*
Your Active Policy Number*
First Name*
Last Name*
Personal Email*
Phone Number*
Are you affiliated with NATO Forces?*YesNo
Where will the vehicle be registered?*USAREURBFGGerman registry
Are you married?*YesNo
Date of Birth*
Vehicle Make*
Vehicle Model*
Year of Vehicle*—Please choose an option—20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990
VIN - Vehicle Identification Number
Horse Power*
Actual Cash Value in USD* (max. value 95,000 USD)
Is there a lien on your vehicle?*YesNo
Have you had any at-fault accidents in the last five years?*YesNo
Third Party Liability Insurance incl. Motor Assistance Coverage (mandatory)* Yes
Comprehensive Coverage (e.g. theft, broken windshield, natural hazard) Deductible 300 EUR* YesNo
Collision Coverage (own damage) Deductible 500300 EUR (Note: If you select to have Collision Coverage, you will also carry Comprehensive Coverage with a 300 EUR deductible)* YesNo
Loyalty Repair Program?* YesNo
Effective Date of Coverage*
PCS Date / DEROS
Promotion Code
10% Discount Active
Invalid Promotion Code
10% - 4th of July10% - USYS2023none
I hereby consent to my data submitted in the contact form being collected and processed in order to answer my request. Please note: You can withdraw your consent anytime via email to privacy@mirascon.com.
Please note: You can withdraw your consent anytime via email to privacy@mirascon.com. Please see our privacy statement for detailed information about user data handling.
Third Party LiabilityThird Party Liability & Comprehensive CoverageThird Party Liability & Collision Coverage (incl. Comprehensive Coverage)
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Email*
I accept the privacy terms and conditions.*
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