MIRASCON

Your Data

First name*

Last name*

Date of birth*

Email*

Phone number*

Are you affiliated with NATO Forces?*

Yes
No

Where will the vehicle be registered?*

USAREUR
BFG
German registry

Additional Information

Have you had any accidents or claims in the last 5 years?

Yes
No

Are you married?

Yes
No

Do you already have a policy with us?

Yes
No

If yes, what is your policy number?

Your Vehicle

Year of vehicle*

Please enter the year of the first registration. If the vehicle is older than 25 years please contact us 0800-MIRASCON (0800-64727266) or send us an email at contact@mirascon.com for a quote.

Car make*

Car model*

Horse Power (hp)*

Actual cash value in USD*

If your auto value exceeds 80,000 USD, please contact us at 0800-MIRASCON (0800-64727266) or send us an email at contact@mirascon.com for a quote.

Is there a lien on your vehicle?*

Yes
No

Lienholder name

Your Insurance Coverage

Third Party Liability Insurance incl. Motor Assistance Coverage (mandatory)*

Yes

Comprehensive Coverage (e.g. theft, broken windshield, natural hazard)Deductible 300 EUR*

Yes
No

Collision Coverage (own damage)Deductible 500 EUR (Note: If you select to have Collision Coverage, you will also carry Comprehensive Coverage with a 300 EUR deductible)*

Yes
No

Loyalty Repair Program?*

Yes
No

Expected start of insurance coverage (mm/dd/yyyy)*

PCS Date / DEROS (mm/dd/yyyy)

Data Processing*

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