Quotation - Car & Household
 
 
  Personal Information:
     
  Date
  Reference number
  Title
  Initials
  Surname
  Id number
     
  Address:
   
 
   
  Code:
 
   
  Please complete the fields below:
     
  Marital status
  Land line
  Mobile
  Email
     
  Are you currently insured
     
  Yes
  No
   
  Please complete the fields below:
     
  With whom are you insured
  Policy Number
     
   
  Have you claimed in the last five years?
   
  Please complete the fields below:
     
  Date
  Type of claim
  Amount
     
  Please complete the fields below:
     
  Date
  Type of claim
  Amount
     
   
  All Risk.
   
  Please complete the fields below:
     
  Item
  Description
  Value
     
 
     
  Item
  Description
  Value
     
 
     
  Item
  Description
  Value
     
 
     
  Item
  Description
  Value
     
 
     
  Item
  Description
  Value
     
 
     
  Item
  Description
  Value
     
   
  Vehicles.
   
  Vehicle A:
     
  Type of vehicle
  Model / Make
  Registration number
  Year model
  Value
  ID number of driver
  Radio / Cd value - Vehicle
  Date licence obtained
  Licence code
  No claim bonus
  Regular driver
  Financing - Vehicle
     
  Pensioner:
     
 
   
  Business:
     
 
   
  Age:
     
 
   
  Type of Insurance:
     
 
   
  Road side assistance Required:
     
 
   
  Locked up garage:
     
 
   
  Vehicle hire Required:
     
 
   
  Radio / Cd insurance coverage Required:
     
 
   
  Locked gate at night:
     
 
   
  Fixed excess Required:
     
 
   
  Vehicle Security:
     
 
   
  Vehicle B:
     
  Type of vehicle
  Model / Make
  Registration number
  Year model
  Value
  ID number of driver
  Radio / Cd value - Vehicle
  Date licence obtained
  Licence code
  No claim bonus
  Regular driver
  Financing - Vehicle
     
  Pensioner:
     
 
   
  Business:
     
 
   
  Age:
     
 
   
  Type of Insurance:
     
 
   
  Road side assistance:
     
 
   
  Locked up garage:
     
 
   
  Vehicle hire Required:
     
 
   
  Radio / Cd insurance coverage Required:
     
 
   
  Locked gate at night:
     
 
   
  Fixed excess Required:
     
 
   
  Vehicle Security:
     
 
   
  Choose Vehicle and complete the fields below:
     
 
   
 
     
  Model
  Registration number
  Year model
  Value
     
  Household Information, Building
     
  Value?
  Security Complex?
  Thatch roof?
  Brick House?
  Standard Roof?
  No Claims Bonus?
  Date moved into residence?
  Fencing higher than 1.8 Meters?
     
  Household Information, Contents:
     
  Value?
  Alarm connected?
  Security gates?
  Security bars on windows?
  Security Complex?
  Thatch roof?
  Brick House?
  Standard Roof?
  No Claims Bonus?
  Date moved into residence?
  Fencing higher than 1.8 Meters?
     
  Who referred you to our business: