Short Term Insurance

Short Term Insurance

Questionnaire for comparative or new quotations
Client Information

Please complete this mandatory section.
Name & Surname

TtitleFirst NameLast Name
ID Number
Physical Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
eg@example.com
Marital Status
Insurance Information

Please provide us with your short term policy schedule if you are currently insured
How many months have you had uninterrupted insurance?
Current Insurer
Previous Insurer(s)
ITC Check

Kindly note that short - term Insurers require permission to perform an ITC (credit score check) in order to provide a client with quotations. The credit score check is mandatory. If you do not provide consent, then please note that we will not be able to assist you.
Do you consent to an ITC check to be performed by quoted Insurers?
Claims History

Kindly note that we need to request a written claims history letter for the last 3 years, from your current and / or previous insurer. We cannot provide quotations without this information.
Number of Motor Claims in the past 5 years
Value of Motor Claims in the past 5 years
Number of House Content Claims in the past 5 years
Value of House Content Claims in the past 5 years
Number of Building Claims in the past 5 years
Value of Building Claims in the past 5 years
Vehicle 1

Please complete this section if applicable
Are you the registered owner of this vehicle?
If you are not, then we will require the registered owner's details to prove financial interest
Registered owner: license type
Registered owner: original year in which license was issued
Vehicle: year of manufacture
Vehicle: make
Vehicle: model
M&M Code
This code usually appears on the invoice provided from the dealership when purchasing a vehicle
What type of cover do you require?
What do you use your vehicle for on a daily basis?
Are you the regular driver of this vehicle?
Only complete the following sections if you are not the regular driver, but your spouse, child or other family member is
Regular driver: Name and Surname

First NameLast Name
Regular driver: ID number
Regular driver: license type
Regular driver: original year in which license was issued
Regular driver: contact number
Please enter a valid phone number.Format: +27.
Regular driver: email address
example@example.com
Security measures for overnight parking:
the overnight parking should match your physical address
Security measures for day - time parking:
Day - time parking address: Only complete if it differs from the night - time address

Street Address

Street Address Line 2

CityProvince

Postal code
Please list any additional non factory fitted items with their nominated value's.
Do you require vehicle hire?
This benefit is encouraged.
Vehicle 2

Please complete this section if applicable
Are you the registered owner of this vehicle?
If you are not, then we will require the registered owner's details to prove financial interest
Registered owner: license type
Registered owner: original year in which license was issued
M&M Code:
This code usually appears on the invoice provided from the dealership when purchasing a vehicle
What type of cover do you require?
What do you use your vehicle for on a daily basis?
Vehicle: year of manufacture
Vehicle: make
Vehicle: model
Are you the regular driver of this vehicle?
Only complete the following sections if you are not the regular driver, but your spouse, child or other family member is
Regular driver: Name and Surname

First NameLast Name
Regular driver: ID number
Regular driver: license type
Regular driver: original year in which license was issued
Regular driver: contact number
Please enter a valid phone number.Format: +27.
Regular driver: email address
example@example.com
Security measures for overnight parking:
The overnight address should match your physical address
Security measures for day - time parking
Day - time parking address: Only complete if it differs from the night - time address

Street Address

Street Address Line 2

CityProvince

Postal code
Please list any additional Non Factory fitted items with their nominated value's.
Do you require vehicle hire?
This benefit is encouraged.
Buildings:

Please complete this section if applicable
Physical Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Residence type
What is the construction of the roof of your residence?
What is the construction of the walls of your residence?
Is the residence one of the following?
Is there a thatch roof within 5m of the residence (eg. lapa)
Is the residence financed?
Please indicate who the finance house is
What security measures are installed:
What is the nominated value of the residence:
You can choose the following additional benefits at an additional premium:
Contents

Please complete this section if applicable
Physical Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Residence type
What is the construction of the roof of your residence?
What is the construction of the walls of your residence?
Is the residence one of the following?
Is there a thatch roof within 5m of the residence (eg. lapa)
What security measures are installed:
What is the nominated value of the contents
If you do not know the true value, please provide an estimate or we will quote on the minimum amount. An inventory list can be completed for an accurate value of the contents amount.
All Risk: Specified or Unspecified

Please complete this section if applicable
Please confirm the all risk specified / unspecified items that you would like to add to the quotation (Description, Value & IMEI Number)
Outstanding | Additional Information
Please specify any outstanding | additional information that you feel is important for the adviser to be aware of.
Disclaimer:

In accordance with the POPI act and other relevant laws, we are committed to dealing with your personal information in a lawful, legitimate and responsible manner, respecting the privacy of our clients. The Information Officer is: Louis Strydom and can be contacted on louis.strydom@multinetlife.com
Should be Empty:

Short Term Insurance

Client Information

Insurance Information

ITC Check

Claims History

Vehicle 1

Vehicle 2

Buildings:

Contents

All Risk: Specified or Unspecified

Outstanding | Additional Information

Disclaimer: