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La Soufriere Volcano Eruption
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Personal Information
Name
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Last
Work Phone
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Email
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Do you belong to the following group or association?
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BARP - Barbados Association of Retired Persons
What type of job do you do?
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Banking
Clerical / Administrative
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Construction
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Route Taxi Driver
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How long have you consistenly been driving a vechile?
*
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Vehicle Information
Type of Policy:
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Please select
Private Comprehensive
Private Third Party
Current No Claim Discount:
*
Please select
No Discount 0%
1 Year Claim Free 30% Discount
2 Years Claim Free 40% Discount
3 Years Claim Free 50% Discount
4 Years Claim Free 60% Discount
What is the make and model of the vehicle?
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What is the type of body?
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Please select
Hard Top
Pick Up
Soft Top
Vehicle Type
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Please select
Standard
Pick Up
Van
Reconditioned
High Performance - Non Standard Vehicle
Year of manufacture:
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Engine Size (cc):
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Is it a right hand drive vehicle?
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Yes
No
What is the value?
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Comments
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