Insured
ID Number
Current Insurer
Contact number
Occupation
Cell number
E-Mail adress
 
Personal Information
 
House Contents
NCB ( No claim bonus ).
24 Hour linked alarm?
Risk adress
Burglar bars to ALL open windows?
Security Gates to ALL outside doors? (incl sliding doors)?
How long at current address?
Thatch roof?
Type of dwelling  ( Apartment, private dwelling etc. )
Standard construction?
Have you had claims in the last 5 years?
Estimation of total claims in rand value?
Replacement value of contents
Accidental, Mechanical, Electrical & Electronic damage To house contents, including desktop computer equipment?
 
Personal All Risks
Unspecified  Clothing and Personal Effects        
Bicycles
Cellphones
Any personal belongings that you want to specify individually?:
 
VEHICLE COVER
Registered Owner
Overnight Parking
Year Manufactured
VESA approved Immobilizer?
Make
Gear Lock?
Model
Tracking Device?
Netstar, Tracker and other?
NCB ( No claim bonus )
Radio/Tape/CD Player/Shuttle
Canopy/Mags/Sunroof
Use of vehicle
Type of cover
Waiver of excess
Car Hire
 
I hereby certify that the above information is correct.
 
Do you prefer contact by :
E-mail
Contact numbers
or both
QUOTATION
Auto Dealers Value + extras
Notes