Contact Details: Landline: Cell: Address: Postal Code: Year: Claim Type: Claim Value: Household Contents (Primary Residence):
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1 QUOTE FOM PESONAL DETAILS Name: ID Number: Surname: Marital Status: Occupation / Business: Contact Details: Landline: Cell: PEVIOUS INSUANCE DETAILS Current Insurer: Permission to do ITC check: YES NO ITC Checks are performed in accordance with insurers need to accurately assess risk. Information obtained is used solely for this purpose. Claims History: COVE EQUIEMENTS Household Contents (Primary esidence): esidence: Accidental Damage Cover: Mechanical / Electrical Breakdown Cover: Power Surge Cover: Cover for Damage by Wild Baboons & Monkeys: Insured Amounts esidence Type: House (Fully detached): Duet: Townhouse: Flat :(Ground Level) Flat (Above Ground Level): Other (Describe):
2 QUOTE FOM Security Measurements: (Please tick where applicable) Burglar Proofing (All Windows): Burglar Proofing (Only Opening Windows): Security Gates: Electric Fence: Alarm System (Linked to Armed esponse): Alarm System (Not Linked): Is the residence in a high security complex with access control, 24 hr security patrols and Electric Fence? YES NO Household Contents (Primary esidence): esidence: Accidental Damage Cover: Mechanical / Electrical Breakdown Cover: Power Surge Cover: Cover for Damage by Wild Baboons & Monkeys: Insured Amounts esidence Type: House (Fully detached): Duet: Townhouse: Flat :(Ground Level) Flat (Above Ground Level): Other (Describe): Security Measurements: (Please tick where applicable) Burglar Proofing (All Windows): Burglar Proofing (Only Opening Windows): Security Gates: Electric Fence: Alarm System (Linked to Armed esponse): Alarm System (Not Linked): Is the residence in a high security complex with access control, 24 hr security patrols and Electric Fence? YES NO Household Contents (Secondary esidence): Insured Amounts esidence: Power Surge Cover: Accidental Damage Cover: Cover for Damage by Wild Baboons & Monkeys: Mechanical / Electrical Breakdown Cover: House (Fully detached): esidence Type:
3 QUOTE FOM Duet: Townhouse: Flat :(Ground Level) Flat (Above Ground Level): Other (Describe): Security Measurements: (Please tick where applicable) Burglar Proofing (All Windows): Burglar Proofing (Only Opening Windows): Security Gates: Electric Fence: Alarm System (Linked to Armed esponse): Alarm System (Not Linked): Is the residence in a high security complex with access control, 24 hr security patrols and Electric Fence? YES NO ALL ISKS Unspecified All isks: Insured Amount: Specified Items: Description Insured Amount: MOTO VEHICLES Vehicle 1 - Owner & Driver Details egular Driver Name: egular Driver ID No: Date of First Licence: egular Driver Surname: egular Driver Licence Code (E.g. EB, B, C1): Driver Code: Does egular Driver Have a Three University Degree? YES NO Vehicle 1 - egular Driver Claims History: Vehicle 1 - Cover equired Vehicle 1 - Additional/Optional Cover:
4 QUOTE FOM Car Hire: Excess Waiver: oadside Assist: Vehicle 1 - Vehicle Details egistration Number: Vehicle 1 - Type of Use: Private: Private & To Work: etired: Business: Vehicle 1 - Overnight Parking: Vehicle 1 - Security: Vehicle 2 - Owner & Driver Details egular Driver Name: egular Driver ID No: Date of First Licence: egular Driver Surname: egular Driver Licence Code (E.g. EB, B, C1): Driver Code: Does egular Driver Have a Three University Degree? YES NO Vehicle 2 - egular Driver Claims History: Vehicle 2 - Cover equired Vehicle 2 - Additional/Optional Cover: Car Hire: Excess Waiver: oadside Assist: Vehicle 2 - Vehicle Details egistration Number: Vehicle 2 - Type of Use: Private: Private & To Work: etired: Business: Vehicle 2 - Overnight Parking: Vehicle 2 - Security:
5 QUOTE FOM Vehicle 3 - Owner & Driver Details egular Driver Name: egular Driver ID No: Date of First Licence: egular Driver Surname: egular Driver Licence Code (E.g. EB, B, C1): Driver Code: Does egular Driver Have a Three University Degree? YES NO Vehicle 3 - egular Driver Claims History: Vehicle 3 - Cover equired Vehicle 3 - Additional/Optional Cover: Car Hire: Excess Waiver: oadside Assist: Vehicle 3 - Vehicle Details egistration Number: Vehicle 3 - Type of Use: Private: Private & To Work: etired: Business: Vehicle 3 - Overnight Parking: Vehicle 3 - Security: CAAVAN, Make & Model Value: Parking: Use: Cover: egistered Owner TAILE, Make & Model Value: Parking: Use: Cover: egistered Owner
6 QUOTE FOM MOTOCYCLE egular ider Name: egular ider ID No: egular ider Surname: Date of First Licence: egular ider Claims History: Cover equired Motorcycle Details egistration Number: Overnight Parking: Security: WATECAFT Owner ID No: Name: Hull Length: : Motor/s Type: Inboard Outboard Type of craft: Motor/s Size Value: ADDITIONAL COVE OPTIONS (would you want more information on the following?) Personal Legal Liability: YES NO Personal Accident: YES NO Signature Date: d d m m c c y y
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