| |
! = invullen verplicht |
|
| |
|
|
| verzekeringsmaatschappij |
_____________________________ |
|
| |
|
|
| Opdrachtgever |
|
|
| naam |
_____________________________ |
! |
| emailadres |
_____________________________ |
! |
| |
|
|
| Eigenaar |
|
|
| naam |
_____________________________ |
! |
| adres |
_____________________________ |
! |
| postcode |
_____________________________ |
|
| woonplaats |
_____________________________ |
! |
| telefoon |
_____________________________ |
|
| mobiel |
_____________________________ |
|
| |
|
|
| Taxatie adres indien anders |
|
|
| naam |
_____________________________ |
|
| adres |
_____________________________ |
|
| postcode |
_____________________________ |
|
| woonplaats |
_____________________________ |
|
| |
|
|
| Object
aanvinken: |
[ ] personenauto
[ ] bromfiets
[ ] motorfiets
[ ]
kampeerauto
[ ] overig:____________________
|
|
| merk |
_____________________________ |
|
| type |
_____________________________ |
|
| kenteken |
_____________________________ |
|
| bouwjaar |
_____________________________ |
|
| |
|
|
| Taxatie: |
|
|
| voorkeursdatum |
_____________________________ |
|
| eerder taxatierapport aanwezig |
[ ]
ja [ ]
nee |
! |
| betaling taxatie |
[ ] contant [ ] via de bank ! |
| opmerkingen: |
|
|
