Test Page - Earnest Insurance

Your Personal Details

First Name

Last Name

Contact Number

Subject / Inquiry Type

Request a Quote

Message

Property Insurance

Liability Insurance

Group Medical Insurance

Travel Insurance

Marine Insurance

Other

Preferred Contact Method

Email Phone

I agree to the Privacy Policy and consent to my data being used to respond to my inquiry.

Motor Insurance

Mobile Number

Date of Birth

Nationality

Email Address

Details of Additional Drivers (If Any)

Do you have a driving experience from your home country

Yes No

Do you currently have motor insurance?

Yes No

If yes, please tell us your current insurer:

If yes, what type of cover you currently hold?

Third-Party Only Comprehensive Not Sure

Vehicle Details

Vehicle Make

Vehicle Model

Vehicle Spec/Trim

Insured Value(AED)

Manufacturing Year

Will there be an Auto loan/vehicle mortgage involve?

Additonal Information (if any))

Medical Insurance

Date of Birth

Gender

Email Address

Nationality

Emirate of Visa

Relationship with sponsor

Marital Status

Any Pre-Existing Condition

Hospital Coverage preferences

Home Insurance

Residency Status

Resident of UAE Non Resident of UAE

Ownership Status

Owner Tenant

Type of Occupancy

Homeowner Living in My Home Homeowner Renting My Home Tenant Renting a Home

Property Address

Is Home Mortgaged ?

Yes No

Name of The Bank

What coverage are you looking for?

Building Contents Personal Belongings

Sum Insured of Building

Contents

* Contents include desktop computer, audio-visual equipment, stamp, coin or medal collections, curios, pictures or otherwise works of art, rugs or carpets, articles of gold, silver or other precious metals, Jewelery or fur.

Personal Belongings

* Personal Belongings means watches, sports equipment, luggage, portable equipment (e.g. laptop) photographic equipment, musical instruments, clothing and other items that are designed to be worn or carried.

Domestic Helper?

Yes No

Name

Date of Birth

Nationality

Is your home built of concrete?

Yes No

Is the home equipped with a security system?

Yes No

Is the home equipped with a fire/smoke alarm system?

Yes No

Are all external doors and windows equipped with locking system?

Yes No

Is the home occupied during day time?

Yes No

Number of bedrooms in your home?

Number of adults living in your home?

Number of children living in your home?

Is the home within 400m of water?

Yes No

Have you suffered any losses (claims) in the past year?

Yes No

Will your home be left un-occupied for more than 60 days?

Yes No

Will the property be leased for period of less than 12 months?

Yes No