insurance.thaivisa.com

CTPL Insurance

Name *

Thaivisa Username		used if we cannot contact by email for any reason

Address *


D.O.B *


Day *

Year *

Month *

Telephone No *

Email Address *

Confirm email *

Type of Vehicle *	Motor Bike: >75CC <125CC Motor Bike: >125CC <150CC Motor Bike: >150CC Car (Includes 4 door pickups registered as Saloons) Van Pickup (2 Door)

Make

Model

Renewal of Road Tax Required	Yes No

Present provider (if any)


Current policy expiration date


Year

Day

Month

Year


Any Comments ?


Comments

Submit the form above online, or post or fax it to us: AA INSURANCE BROKERS CO., LTD. 565/62 Moo 10 (Next to Big C) South Pattaya Nongprue, Banglamung Chonburi 20150, Thailand Fax: 038 374 251 Int. Fax +66 38 374251 Skype: aainsure Click for printable version