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Application:

  
     
 

Lead Form:

For a printed version of the application form, please click here....
Please fax completed form to 011 865 5611

Or

Please complete the form in order for us to give you a quote.

  
     
     
 
NAME:
SURNAME:
ID NUMBER:
PHYSICAL ADDRESS:
AREA CODE:
TELEPHONE NUMBER:
FAX:
CELL:
OCCUPATION:
COVER REQUIRED:  
BUILDING:                                                R
CONTENT:                                                R
TOWN HOUSE: Yes    No 
CLUSTER: Yes    No 
DETACHED HOUSE: Yes    No 
FLAT: Yes    No 
GROUND: Yes    No 
ABOVE GROUND: Yes    No 
TILE ROOF: Yes    No 
THATCH: Yes    No 
BURGLAR BARS: Yes    No 
SECURITY GATES: Yes    No 
LINKED ALARM: Yes    No 
ACCESS CONTROL: Yes    No 
24 HOUR SECURITY: Yes    No 
ELECTRIC FENCE: Yes    No 

ALL RISKS:

  
CELL PHONES:                               R
JEWELRY:                                        R
LAP TOPS:                                       R
VIDEO/DIGITAL CAMERAS:       R
CAR RADIOS:                                  R
BICYCLE:                                           R
SPECTACLES:                                  R
OTHER:
   

VEHICLES:

  
VEHICLE 1: VEHICLE 2:
MAKE: MAKE:
MODEL: MODEL:
YEAR: YEAR:
KM: KM:
ALARM: ALARM:
IMMOBILIZER:    IMMOBILIZER:   
GEAR LOCK: GEAR LOCK:
TRACKING TRACKING

USE:

  

USE:

  
PRIVATE PRIVATE:

WORK AND BACK:

WORK AND BACK:
BUSINESS: BUSINESS:
NUMBER OF YEARS WITH OUT CLAIMING:
WHEN WAS DRIVERS LICENSE OBTAINED:
CLAIMS HISTORY:

ARE YOU CURRENTLY INSURED?

 Yes No

WITH WHOM?

WHAT IS YOUR CURRENT PREMIUM?

HOW LONG HAVE YOU BEEN WITH THIS COMPANY?
PREVIOUS INSURERS?

 

  
 

 
     
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