Short-Term Insurance

1. Your Details
Title:
  • Mr.
  • Mrs.
  • Miss
  • Dr.
  • Prof.
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This question is required.
Name:
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Surname
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ID Number:
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Phone Number:
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Email Address:
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2. What is your physical address? (this is the address where we will assume the insured items are kept)
Street/complex details:
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Suburb:
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City:
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Postal Code:
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3. Do you currently have insurance on the items you would like a quote on?
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3.1. Since when have you had this insurance?
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3.2. With which insurance company?
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4. Have you, or any member of your household:
4.1. Ever been offered insurance on special conditions, had a policy cancelled or renewal refused or policy declined?
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4.1.1. Please provide details:
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4.2. Been involved in a motor accident or suffered any other loss during the last 5 years?
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Claim Details:

Date of Claim:
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Type of Claim
  • - select a option -
  • Motor Accident
  • Theft
  • Damage
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Details (what happened?)
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Claim Amount:
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4.3. Been involved in any civil or criminal litigation in the past 5 years or had any civil judgement against you?
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4.3.1. Please provide details:
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5. What kind of insurance are you looking for?
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5.1. What excess are you happy to have on your policy? (the higher the excess the lower the premium)
  • - select a option -
  • R0
  • R500
  • R1000
  • R2000
  • R3000
  • R5000
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Motor Insurance

Vehicle

5.2.1. Cover type requested:
  • - select a option -
  • Comprehensive
  • Theft and third party only
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5.2.2. Vehicle registration number
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5.2.3. Who is the regular driver?
  • - select an option -
  • Myself
  • Spouse
  • Other
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Name:
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ID Number:
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Licence Code:
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Year license was granted
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Relationship to you
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5.2.4. Is the vehicle currently financed?
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What is the outstanding balance?
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5.2.5. Is the vehicle new or secondhand?
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5.2.6. Would you like car hire included?
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5.2.7. Does the car have any non standard accessories eg mags, radio etc?
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Please list the accessories:

Accessory
Accessory Name:
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Accessory Value:
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5.2.8. Is the vehicle modified in any way
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5.2.9. Does the vehicle have any existing damage?
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5.2.10. Does the vehicle have a soft top?
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5.2.11. Do you need 4x4 cover?
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5.2.12. For what use is your car?
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5.2.13. Where is your car parked during the day?
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Type of parking:
  • - select a option -
  • Open
  • Under cover
  • Security complex
  • Secure parking garage
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5.2.14. Where is your car parked during the night?
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Type of parking:
  • - select a option -
  • Locked garage
  • In the yard behind an electric gate
  • In the yard behind a manual gate
  • In the yard with no gate
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Field is required!
5.2.15. Does your car have:
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Please select which tracker
  • - select a option -
  • Autotrak
  • Bandit
  • Beam E
  • Bidtrack
  • Cartrack
  • Ctrack
  • Digit
  • FM200/300
  • Matrix
  • Mobility Tracker
  • Mtrack
  • My Tracer
  • Netstar
  • Selftrack
  • Smartrak
  • Tracetec
  • Tracker
  • Other
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Field is required!
Please stipulate which tracker
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Building Insurance

5.3.1. Property Type
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5.3.2. Building Wall Type
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5.3.3. Will the property be unoccupied for more than 7 consecutive days in the first 30 days of cover?
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Field is required!
5.3.4. Is the property unoccupied during working hours?
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5.3.5. Is the property unoccupied for more than 60 days in a year?
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Field is required!
5.3.6. Do all opening windows on the ground floor have burglar bars?
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Field is required!
5.3.7. Do all access doors have fitted security gates?
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Field is required!
5.3.8. Does a garage or outbuilding adjoining the house have an inter-leading door?
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Field is required!
5.3.9. Does the property have a boundary fence or wall at least 1.8m high?
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Field is required!
5.3.10. Is the property in a security complex with restricted access?
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Field is required!
5.3.11. Does the property have an alarm system?
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Field is required!
5.3.11.1. Does the alarm system have a radio link?
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5.3.12. Roof type
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5.3.13. Do you have a solar geyser?
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5.3.14. Do you have a registered bond on the property?
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What is the outstanding balance?
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Household Contents Insurance

5.4.1. What is the value of the household contents you wish to insure?
Please note, you must give us the value to replace all your goods in the house, not what you bought them for.
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5.4.2. Do you have any outstanding credit on any of your household items?
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5.4.2.1. How much outstanding credit is there?
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Field is required!
5.4.3. Do all opening windows on the ground floor have burglar bars?
Field is required!
Field is required!
5.4.4. Do all access doors have fitted security gates?
Field is required!
Field is required!
5.4.5. Does a garage or outbuilding adjoining the house have an inter-leading door?
Field is required!
Field is required!
5.4.6. Does the property have a boundary fence or wall at least 1.8m high?
Field is required!
Field is required!
5.4.7. Is the property in a security complex with restricted access?
Field is required!
Field is required!
5.4.8. Does the property have an alarm system?
Field is required!
Field is required!
5.4.8.1. Does the alarm system have a radio link?
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Field is required!

All Risk Cover

5.5. Please list the items you wish to cover

Item:

Item Name:
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Model/Year:
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Replacement Value:
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5.6. You will also need cover for general all risk to cover things like a handbag, clothes, cash - things that could be stolen off you or out of your car for example.
What Rand value do you want covered for general items?
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