Please complete the details below
Please note that your answers may disqualify you from receiving an estimate or application
ex. 703 Green Heights Bldg , 1-9-22 kyobashi Chuo-ku
Questions about the automobile to be insured.
Please write down the vehicle code (kata-shiki), the manufacturers name and model of vehicle.
Refer to the Shaken document. check here
・Manufacturers name, model, year of vehicle
・vehicle code（型式 : katashiki）
Vehicle's current value
Initial registration date.（初度登録 : Shodotouroku）
Select the purpose of your car.
The main driver's date of birth.
Youngest driver in family.
Other people beside the family member will drive the car occasionally
Select the color of your driver's license.
Questions about current automobile insurance.
Do you have auto insurance currently?
Current policy maturity date
(If you don't have insurance, when would you like it to commence)
How many times have you had an accident in the last year?
Please select the non-fleet rating*
If you don't know your rating, please select '6'.
note: Driving experience overseas doesn't apply in Japan.
When would you like to start the policy from?
ex. July 1st , ASAP etc.