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INSURANCE QUOTATION

POLICY HOLDER DETAILS

INSURANCE HISTORY

Has any insurer ever declinded to quote?
Has any insurer ever cancelled your insurance?
Has any insurer required an increase in premium or imposed special terms?
Has any insurer refused to renew your policy?
Have you had any convictions/admission of guilt in the last 5 (five) years?

CLAIMS

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

INSURED VEHICLES/MOTORCYCLES

(Use supplementary sheet for additional vehicles/motorcycles)
Financed?
Is a tracking or alarm system fitted?

NAMED DRIVER/RIDER 1

Licence details

NAMED DRIVER/RIDER 2

Licence details

WHERE IS THE VEHICLE/MOTORCYCLE KEPT OVERNIGHT?

DETAILS OF INSURANCE COVER

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

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

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