Quote request

QUOTE REQUEST

Motor and Non-Motor
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Background

Claims for the last 3 years? (Very Important! as we will need this to perform an accurate risk analysis)

CLAIMS INFO

	Date of Incident	Section	Payout
Claim 1
Claim 2
Claim 3
Claim 4

COVER OPTIONS
Building

Buildings refers to all structures, e.g. main residence, outbuildings,lapas, boundary walls, etc.

	Full Address	Sum Insured	Roof Construction	Wall Construction	Accidental damage to Fixed Machinery	Power Surge	Geyser Maintenance	Bond noted
Address 1
Address 2
Address 3
Address 4

Contents

Contents refers to contents of all the structures on the premises, for example furniture and personal property in the main house, tools in the garage, etc.

	Full Address	Sum Insured	Roof Construction	Wall Construction	Accidental damage	Power Surge	Mechanical & Electrical Breakdown	Flood:Is the property within 100m from any water source
Address 1
Address 2
Address 3
Address 4

If you answered Yes to the above flood request, please confirm if there were any flood related claims?
All Risk

Here you will need to know what the difference is between specified and unspecified cover (Examples below)

ALL RISK SPECIFIED - This is the items that leaves your premises. For example: Computer equipment, Eyewear, Sports gear, Jewellery, Camping gear, Mobile communication devices, laptops etc.

	Description	Serial Number	Value
Item 1
Item 2
Item 3
item 4

ALL RISK UNSPECIFIED - This is clothing you normally wear; personal effects normally carried on or worn by a person, baby equipment, like prams and children’s car seats.

Amount

Clothing and Personal Effects
Vehicle

Covers motors, motorcycles, classic vehicles, luxury vehicles, 4x4/off-roadvehicle caravans, motor homes, trailers, golf cars, ride-on mowers, shoppingriders and specified accessories.

	Amount
Clothing and Personal Effects

	Vehicle Details	Vin#	Reg#	Car hire	Excess waiver	Credit Shortfall	Accidetal Tyre and Rim
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4

SMART PARK-ONLY APPLICABLE TO SANTAM This is cover only for vehicles that are not driven often and has low mileage each year.

	Vehicle Details	KM Reading	5000km per year	10000km per year	15000km per year
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4

What is SmartPark?
SmartPark is a distance-based vehicle insurance benefit. With SmartPark, your insurance premium will be recalculated and discounted based on the revised number of kilometres you are likely to travel in the foreseeable future – all without having to restructure your policy or compromising your cover.

How does it work?
Your premium discount will be based on kilometres predicted to be travelled within your annual policy renewal period and a percentage discount will be granted within each of the following kilometre bands:
0 – 5 000 km
5 001 – 10 000 km
10 001 – 15 000 km
In order to qualify, you must supply your odometer reading along with your predicted kilometre band.

Kindly note that you would have an additional excess should you go over the above-mentioned limits per year.
I First Name Last Name hereby confirm that all the information above is correct. I hereby grant TitanHB FSP 53428 the permission to quote on my portfolio with the information provided.
Signature

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LETTER OF AUTHORISATION

There is no need to complete the above information if you already have an existing policy. This letter will grant us the permission to request your current schedule and claims on your behalf.
AUTHORISATION TO REQUEST INFORMATION REGARDING CLIENT’S SHORT-TERM INSURANCE PORTFOLIO

I hereby authorize TitanHB FSP 53428 to obtain my policy information & claims history and also to obtain quotations.

It was explained to me, and I understand that this consent may possibly have restricted influence on my constitutional right of privacy.
Date

MonthDayYear
Date
Name

First NameLast Name
ID
Current Policy Number
Signature

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QUOTE REQUEST

Insurance Background

COVER OPTIONS

Building

Contents

All Risk

Vehicle

LETTER OF AUTHORISATION