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INSURANCE QUOTATION

POLICY HOLDER DETAILS

Full Name

Email Address

Risk Address

Code

Phone

ID Number

Postal Code

INSURANCE HISTORY

Present Insurer

Has any insurer ever declinded to quote? *

Yes

No

Has any insurer ever cancelled your insurance? *

Yes

No

Has any insurer required an increase in premium or imposed special terms? *

Yes

No

Has any insurer refused to renew your policy? *

Yes

No

If yes, please supply full details:

Have you had any convictions/admission of guilt in the last 5 (five) years? *

Yes

No

CLAIMS

PLEASE LIST ALL LOSSES OR ACCIDENTS DURING THE PAST THREE YEARS (WHETHER INSURED OR NOT)

Claim date

Type of motor claim

Amount

Claim date

Type of motor claim

Amount

Claim date

Type of motor claim

Amount

INSURED VEHICLES/MOTORCYCLES

(Use supplementary sheet for additional vehicles/motorcycles)

Make:

Year

Model:

Value:

Financed? *

Yes

No

Is a tracking or alarm system fitted? *

Yes

No

NAMED DRIVER/RIDER 1

Full Name

Licence details *

Full

Learners

Date of Birth

Date obtained

NAMED DRIVER/RIDER 2

Full Name

Licence details

Full

Learners

Date of Birth

Date obtained

WHERE IS THE VEHICLE/MOTORCYCLE KEPT OVERNIGHT?

In a locked up garage

In a locked up yard

In a locked up parking garage

Parked in the street or road

Other

DETAILS OF INSURANCE COVER

Milage under 10 000km/year

Milage over 10 000km/year

CONSENT TO THE USE OF UNDERWRITING, CLAIMS AND OTHER RELEVANT INFORMATION

• Waive any right to privacy in respect of any insurance information provided by you or on your behalf regarding any insurance policy or claim made or lodged by you or on your behalf.
• Allow such information to be disclosed to any other insurance company or its agents.
• Allow us to verify the information provided by you against other legitimate sources or databases.

DECLARATION

All information provided is true and correct

Thanks! We’ll send you a price quote shortly.

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