Note: Information marked with an * is a compulsory field
*Insured *ID Number
Co-Insured ID no / DOB:
Marital Status Policy no.
*Current Insurer Home tel.
*Work Tel. Occupation:
*Cell no.    
*E-mail Address    
If not insured for longer than 39 day: How long?
Has your Insurance ever been cancelled or refused by any Insurer?

House Contents

Note: Information marked with an * is a compulsory field

NCB(No Claims Bonus) *24 hr Linked Alarm?
*Risk Address *Burglar Bars to ALL opening windows?
*How long at current address? *Security Gates to ALL outside doors? (incl sliding doors)?
Postal Address Thatch Roof? Yes No
Type of Dwelling *Value of Property?
Standard Construction? Insured Amount?
Roof Construction? Wall Construction?
*Have you had claims in the last 5 years? Estimation of total claims in rand value?

Accidental, Mechanical, Electrical & Electronic damage To house contents, including desktop computer equipment?

  Insured Amount

NOTES: (iro any added information / requirements or additional cover for second address/holiday home etc.)

Personal All Risks
- Cover -
  Insured Amount:
Unspecified
Clothing and Personal Effects
Specified All risks
Personal Documents
 
 
Transport of groceries and household goods
 
 
Keys, locks and remote control units
 
 
Wheelchairs
 
 
Bicycles
 
 
Bicycles
 
 
Specified Cellphone
 
 
Specified Cellphone
 
  Other
  Other
  Other
  Other
  Other
  Other

Home Owners - Building (Excess: R250)

No Claims Bonus *Address:
*Have you submitted Claims in the last 5 years? Standard Construction?
Estimation of total claims in rand value? Thatch Roof? Yes No
Accidental damage to machinery - Sudden & unexpected damage to machinery of swimming pools, jacuzzis, boreholes, sprinkle irrigation systems, electric gates and garage doors. Insured Amount
Including subsidence and landslip cover?
Yes No
(subject to approval by Underwriter)
NOTES: (iro any added information / requirements or additional cover for second address/holiday home etc.)
VEHICLE COVER

Note: Information marked with an * is a compulsory field
VEHICLE 1
Registered Owner Overnight Parking
*Year Manufactured VESA approved Immobilizer?
*Make Gear Lock?
*Model Tracking Device?
NCB Netstar, Tracker and other?
Regular Driver : ID: How long has he/she had a license?
Regular Driver : ID: How long has he/she had a license?
NCB Netstar, Tracker and other?
* Have you experience and submit any claims in the last 5 years? Voluntary Excess (Amount)
Estimation of total claims submitted? How long have you had Insurance?
Vin Number Radio/Tape/CD Player/Shuttle
Engine Number Canopy/Mags/Sunroof
Registration Number Waiver of excess Yes No
*Private, Business or farming use Car Hire Yes No
*Comprehensive, Limited or 3rd Party Top-up Cover Yes No
Caravan Contents Breakdown Service Yes No
*Insured Amount (Auto Dealers Retail Value)

NOTES: (iro any added information / requirements or additional cover for more vehicles/caravans/motor cycles and or boats)

VEHICLE COVER

Note: Information marked with an * is a compulsory field
VEHICLE 2
Registered Owner Overnight Parking ?
*Year Manufactured VESA approved Immobilizer?
*Make Gear Lock?
*Model Tracking Device?
NCB Netstar, Tracker and other?
Regular Driver : ID: How long has he/she had a license?
Regular Driver : ID: How long has he/she had a license?
* Have you experience and submit any claims in the last 5 years? Voluntary Excess (Amount)
Estimation of total claims submitted? How long have you had Insurance?
Vin Number Radio/Tape/CD Player/Shuttle
Engine Number Canopy/Mags/Sunroof
Registration Number Waiver of excess Yes No
*Private, Business or farming use Car Hire Yes No
*Comprehensive, Limited or 3rd Party Top-up Cover Yes No
Caravan Contents Breakdown Service Yes No
*Insured Amount (Auto Dealers Retail Value)
FAMILY PROTECTION PLAN
Personal Legal Liability Standard (R3000000) R3
Extended Personal Legal Liability R10mil for R10 or R20mil for R20
Legal Access (Legal Costs for Civil or Crimanal charges for or against the insured) R30000 for R30 / R60000 for R50 / R100000 for R70
Personal Accident R1000 - R75000
Death Benefit (Funeral Plan) R3000 / R5000 / R7500 / R10000
Hospital Benefit Plan R50 / R100 / R150 / R200 / R250 / R300 / R350 / R400