QUOTE REQUEST
AUTO INSURANCE GERMANY

  • 1

    Personal Information

  • 2

    Vehicle Information

  • 3

    Coverage & Submit

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Personal Information

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*

Do you already have a policy with us?*YesNo
What is your policy number?
Car Make*
Car Model*
Year of Vehicle*
VIN - Vehicle Identification Number
Horse Power*
Actual Cash Value in USD* (max. value 80,000 USD)
Is there a lien on your vehicle?* YesNo
Please specify the registered name on the lien:
Have you had any at-fault accidents in the last five years?*YesNo

Third Party Liability Insurance incl. Motor Assistance Coverage (mandatory)*
Yes
Important note: Comprehensive and collision coverage are only available for cars not older than 10 years. However, cars financed by a bank are required to get full coverage (comprehensive & collision).
Comprehensive Coverage (e.g. theft, broken windshield, natural hazard) Deductible 300 EUR*
YesNo
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)*
YesNo
Loyalty Repair Program?*
YesNo
Effective Date of Coverage*
PCS Date / DEROS
How did you find out about MIRASCON?
Please specify
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 see our privacy statement for detailed information about user data handling.