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Car and Household Insurance Quotation Form

Please complete the form below if you need a quotation on Car and Household Insurance as well as any additional items.

For Car Insurance only, complete this form.

VEHICLE 1
Title
First Name
Surname
ID Number
Date of Birth
Tel no & code
E-mail
Occupation
Residential Suburb
Postal Code
Marital status
Previous insurer(s)
How long in total?
Amount of claims
Value of claims
Current Premium

GENERAL DETAILS
Has an insurer ever refused any proposal of yours, cancelled any policy (or section thereof), refused to renew any policy (or section thereof) or imposed any special conditions? YES NO (If YES, supply details below)


House Contents
Type of residence
Value of contents
Date you moved in

Any burglaries?	Yes No	If yes, date:

Security measures	Burglar bars at all openable windows Gates at all doors leading outside Linked alarm (Monitoring) Linked alarm (Armed response) Electric fencing Complex with controlled access 24-hour security guards

Claim-free years

BUILDING
Used as
Residential suburb
Postal code
Insured amount

ALL RISKS (UNSPECIFIED)
Insured amount

ALL RISKS (SPECIFIED)
Item 1 description	Value:
Item 2 description	Value:
Item 3 description	Value:
Item 4 description	Value:
Item 5 description	Value:

Year, make & model
Value
Overnight parking
Vehicle cover
Radio cover value
Vehicle security	Alarm/Immobiliser Gearlock Anti-hijack Tracking device
Details of driver
License Obtained	(indicate year)
Claim-free years	(of regular driver)

VEHICLE 2
Year, make & model
Value
Overnight parking
Vehicle cover
Radio cover value
Vehicle security	Alarm/Immobiliser Gearlock Anti-hijack Tracking device
Details of driver
License Obtained	(indicate year)
Claim-free years	(of regular driver)

OTHER ITEMS
Description & value

I give you permission to check my credit record.

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