Domestic Insurance Quote

Please fill in all of the details in the fields below. If at any time you are not sure of any of the details you are required to fill in please don't hesitate to contact us for further information.

1. Client Details
1a. Full Name
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1b. Physical Address
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1c. Occupation
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1d. ID no.
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1e. Phone no.
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1f. Cell no.
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1g. Email Address
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1h. Fax no.
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1i. Postal Address
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1j. Do you qualify for a pensioner discount.
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2. Property Details
2a. Age of house
:
 Years
Construction
2b. Roof
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(If other selected)
2c. Walls
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(If other selected)
2d. Other Construction
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2e. Current occupancy status
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3. Insurance Value
3a. Building sum insured
:
 R  
3b. Contents sum insured
:
 R  
3c. Unspecified all risks
:
 R  
3d. Specified all risk items
:
4. Security Details
4a. Burglar bars on all opening windows and security gates on all external doors.
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4b. Alarm linked to 24hr armed response.
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Sensors
4c. Infra Red
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4d. Glass Breakage Detector
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4e. Other
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4f. Is your home occupied during the day?
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4g. Details of any other protections
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4h. Is your property within a 1km radius of the following
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4i. Have you made a claim in the last 5 years?
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4j. Details of all claims with settlement amounts.
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4k. Have you ever had any insurance cancelled or declined or had any restrictions endorsed on your policy?
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4l. Have you ever been charged or convicted of any criminal offence or declared bankrupt?
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4m. Current insurer
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4n. Prevous insurer
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5. Vehicle Details
5a. Make
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5b. Year of registration
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5c. Sedan, LDV
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5d. Engine capacity
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5e. Transmission
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5f. Accessories / modifications
(please give details and value)
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5g. Estimated retail value of vehicle
:
 R
5h. Suburb in which the vehicle will be parked at night
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5i. Where will it be parked
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5j. Suburb in which the vehicle will be parked during the day
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5k. How often is the car used
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5l. Approximate distance traveled
per year (km)
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5m. What purposes is the vehicle mainly used for
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5n. What is the ownership status of the vehicle
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5o. Do you require radio cover?
(supply make, model and value.)
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6. Security information
6a. Does the vehicle have any
anti-theft equipment?
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6b. If yes, please specify
:
Hold Ctrl to select multiple
6c. Other
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7. Driver information
7a. Name and age of regular driver
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7b. Gender
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7c. Occupation
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7d. How long has this driver held a SA drivers license?
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7e. Details of any traffic offences, license suspension, cancellation or endorsement in the last 5 years.
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7f. Are you entitled to a
No Claim Bonus?
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7g. If yes, please specify what rating
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7h. Have you claimed in the last 5 years?
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(enter 99 if you have never claimed)
7i. Names and ages of other drivers
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7j. Gender
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7k. Percentage of use
:
 %
8. Previous Details
8a. Previous insurer
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8b. Current insurer
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8c. Current premium
:
 R  
8d. Any other notes you wish to include
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