Vehicle Insurance Quotation
Needs Analysis
Name
*
First Name
Last Name
Identity Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Occupation
*
Has any insurer ever cancelled your insurance policy or refused renewal?
*
Please Select
Yes
No
Has any insurer ever given you notice to cancel your insurance policy
*
Please Select
Yes
No
Current Insurance Company
*
For how long have you had vehicle insurance without any break in cover?
*
Please Select
No Previous / Current Insurance
Less than a year
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years +
No insurance cover for 30 days or longer is considered a break in cover
Vehicle 1
Vehicle Year
*
Example: 2015
Vehicle Make
*
Example: Toyota
Vehicle Series
*
Example: Corolla 1.8i CVT
Vehicle Color
*
Example: Metallic Blue
Regular Driver
*
First Name
Last Name
Registered Owner
*
Please Select
I am the registered owner
Someone else is the registered owner
The vehicle is registered in a company name
Names & ID number of registered owner (If different from policyholder)
Regular Driver ID Number
*
Driver's Licence Code
*
Example: B / EB / C1 / C / EC / EC1
Driver's Licence Date of First Issue
*
Does the vehicle have a tracking device?
*
Please Select
Yes
No
Night Parking
*
Please Select
Behind locked gates
Locked Garage
Street Parking
Unsecured Yard
Day Time Parking Address
*
Day Time Parking Type
*
Please Select
Street Parking
Open Parking Lot
Parking with access control
Parking with no access control
Basement Parking
Home
Vehicle Use
*
Please Select
Personal including driving to work
Personal, work & client visits
Commercial - Loading of business goods
Taxi / Uber
Vehicle Extras
List each extra and the value of each extra
Car Hire
*
Please Select
Yes - Entry level car
No - I do not require car hire
Yes - Automatic vehicle
Yes - Luxury vehicle
List all vehicle claims or incidents whether insured or not insured at the time in the past 5 years ( year, type and value of each claim)
*
Submit
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