Motor Vehicle 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. Phone no.
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1c. Email Address
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1d. Fax no.
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1e. Postal Address
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1f Do you qualify for a pensioner discount?
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2. Vehicle Details
2a. Make
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2b. Year of registration
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2c. Sedan, LDV
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2d. Engine capacity
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2e. Transmission
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2f. Accessories / modifications
(please give details and value)
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2g. Estimated retail value of vehicle
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 R
2h. Suburb in which the vehicle will be parked at night
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2i. Where will it be parked
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2j. Suburb in which the vehicle will be parked during the day
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2k. How often is the car used
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2l. Approximate distance traveled
per year (km)
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2m. What purposes is the vehicle mainly used for
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2n. What is the ownership status of the vehicle
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2o. Do you require radio cover?
(supply make, model and value.)
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3. Security information
3a. Does the vehicle have any
anti-theft equipment?
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3b. If yes, please specify
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Hold Ctrl to select multiple
3c. Other
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4. Driver information
4a. Name and age of regular driver
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4b. Gender
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4c. Occupation
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4d. How long has this driver held a SA drivers license?
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4e. Details of any traffic offences, license suspension, cancellation or endorsement in the last 5 years.
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4f. Are you entitled to a
No Claim Bonus?
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4g. If yes, please specify what rating
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4h. Have you claimed in the last 5 years?
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(enter 99 if you have never claimed)
4i. Names and ages of other drivers
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4j. Gender
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4k. Percentage of use
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 %
5. Previous Details
5a. Previous insurer
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5b. Current insurer
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5c. Current premium
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 R  
5d. Any other notes you wish to include
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