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ModelActivaActiva IActiva125AviatorGraziaCB ShineShine Sp 125CB StunnerCB TriggerCB TwisterCB UnicornCB Unicorn 160CB Unicorn DazzlerCBF StunnerCBR 150RCBR 250RCBR1000RRCD Dream 110DioDream NeoDream YugaNew DioLIVOStunner PGM F1

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Registration Number*

Year of Manufacture*2006200720082009201020112012201320142015201620172018201920202021

Month of Manufacture*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Type of Vehicle Ownership*IndividualCorporate

Vehicle Requirement*No LienHypothecationHire PurchaseLeaseOther

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ModelActivaActiva IActiva125AviatorGraziaCB ShineCB StunnerCB TriggerCB TwisterCB UnicornCB Unicorn 160CB Unicorn DazzlerShine Sp125CBF StunnerCBR 150RCBR 250RLIVOCD Dream 110DioDream NeoDream YugaStunner PGM F1

Variant

Registration Number*

Year of Manufacture*2006200720082009201020112012201320142015201620172018201920202021

Month of Manufacture*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Type of Vehicle Ownership*IndividualCorporate

Insurance Company*

Insurance Policy Type*—Please choose an option—Third PartyComprehensiveNo

Insurance Expiry Date*

Vehicle Requirement*No LienHypothecationHire PurchaseLeaseOther

Current Premium*

Insured Value*

First Name*

Last Name*

E-mail*

Telephone*

City*

Postal Code*

Comment