If you would like more information

Personal Details
Name and Surname
Telephone Number
Fax Number
Cell number
Email Address
Occupation
I.D Number
Physical Risk Address incl. Postal Code
Postal Address

How many claims/losses in the past 3 years whether insured or not?

What is the total value of these losses?

Has any policy ever been cancelled by an insurer?

If yes, when and which insurer?

Has any insurance/quote been refused by an insurance company?

Has any terms or conditions been imposed by any insurer?


Current insurer?
- from when
Previous insurer?
- no of years?

Household Details
Household Contents Value? (Replacement Value)

How many burglaries/losses in the past 3 years whether insured or not?

Roof & wall construction ie.standard/asbestos/thatch?

Private Dwelling?

Secure Complex ie simplex/duplex?	24hr guard?

Is it a Flat?	Burglar bars on passage side windows with gate on front door?



Home Contents - Safety Measures
Burglar Bars on all opening windows?
Security Gates on all opening doors?
Linked Alarm?
Armed Response?
Is the residence occupied during the day?
Will you be on holiday for the next 60 days?

Will the residence be unoccupied for more than 60 days during any year?

Is anyone at home during the day?
Is the home used for a profession or business?
Is the residence within 2Km of an informal settlement?
Is the residence near an open field or park?
Is there any construction taking place on the residence or nearby?
Do you qualify for a no-claim bonus? (Proof will be required)
Number of Years (No-Claim)

All Risks
Specified/unspecified items: eg. Cell Phone, Watches, etc.
Please indicate value.

Buildings
Building Section: Value (Replacement Value)
Roof and wall construction ie standard/asbestos/thatch?

Motor Vehicles 1
Name of registered owner (must be insured or spouse)
If the vehicle is not registered by either of the above please specify who the owner is, and what their relationship is?

Year
Model & Make (eg. BMW318i)
Retail Value (If unknown we will obtain the value)
Use
Type of cover required?
Do you qualify for a no-claim bonus? (Proof will be required)
Number of claim-free years? (No-Claim)

Motor Vehicle - Safety Measures 1
Immobiliser compulsory (Minimum required VESA level.3)
Gear lock (VESA Approved)
Tracking Device
Where is the vehicle parked overnight?
Car Hire and Roadside Assistance: Please tick appropiate selection/s
accident/theft/writeoff
theft/writeoff only
roadside assistance

Motor Vehicles 2
Name of registered owner (must be insured or spouse)
If the vehicle is not registered by either of the above please specify who the owner is, and what their relationship is?

Year
Model & Make (eg. BMW318i)
Retail Value (If unknown we will obtain the value)
Use
Type of cover required?
Do you qualify for a no-claim bonus? (Proof will be required)
Number of claim-free years? (No-Claim)

Motor Vehicle - Safety Measures 2
Immobiliser compulsory (Minimum required VESA level.3)
Gear lock (VESA Approved)
Tracking Device
Where is the vehicle parked overnight?
Car Hire and Roadside Assistance: Please tick appropiate selection/s
accident/theft/writeoff
theft/writeoff only
roadside assistance

Motor Vehicles 3
Name of registered owner (must be insured or spouse)
If the vehicle is not registered by either of the above please specify who the owner is, and what their relationship is?

Year
Model & Make (eg. BMW318i)
Retail Value (If unknown we will obtain the value)
Use
Type of cover required?
Do you qualify for a no-claim bonus? (Proof will be required)
Number of claim-free years? (No-Claim)

Motor Vehicle - Safety Measures 3
Immobiliser compulsory (Minimum required VESA level.3)
Gear lock (VESA Approved)
Tracking Device
Where is the vehicle parked overnight?
Car Hire and Roadside Assistance: Please tick appropiate selection/s
accident/theft/writeoff
theft/writeoff only
roadside assistance

Please note that if you have failed to disclose any significant facts or circumstances that might influence the insured risk or premium quoted, this will influence the validity of the insurance.