Personal Insurance Quote

Proposal for insurance quotation

Please select your type of cover

Personal Information

ID Number

Title

Name

First Names Last

Email

ID Number

Tel. H

Cell

Home Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Building / Construction Information

Please check relevant items:

Thatch Roof

Yes
No

Value of building in ZAR

Value of house contents in ZAR

Security Information

Alarm with armed reaction

Yes
No

Burglar bars in front of all opening windows

Yes
No

Security gates in front of all outside doors

Yes
No

Remote controlled entrance

Yes
No

Specified Items

E.g. jewelry, cellphones, cameras etc. - Any item out of the house)

Item 1

Value in ZAR

Item 2

Value in ZAR

Item 3

Value in ZAR

Vehicle Information 1

Motorcycle, caravan/trailer, watercraft

Registered owner

Make

Year of model

Model

Value in ZAR

Use

Car Hire

Yes
No

Gearlock

Yes
No

Immobiliser

Yes
No

Must have VESA certificate

Satelite tracking system

Yes
No

Value of radio in ZAR

Vehicle Information 2

Motorcycle, caravan/trailer, watercraft

Registered owner

Make

Year of model

Model

Value in ZAR

Use

Car Hire

Yes
No

Gearlock

Yes
No

Immobiliser

Yes
No

Must have VESA certificate

Satelite tracking system

Yes
No

Value of radio in ZAR

Vehicle Information 3

Motorcycle, caravan/trailer, watercraft

Registered owner

Make

Year of model

Model

Value in ZAR

Use

Car Hire

Yes
No

Gearlock

Yes
No

Immobiliser

Yes
No

Must have VESA certificate

Satelite tracking system

Yes
No

Value of radio in ZAR

Previous / Current Insurance

Did you have previous insurance?

Yes
No

How long

Did you have any claims in the last 5 years?

Yes
No

Date of claim

Description