PERSONAL QUOTE REQUEST

1
Personal Information* This field is required.
MR
MRS/MS
Full Name And Surname
Row 0, Column 0
Row 0, Column 1
Occupation
Row 1, Column 0
Row 1, Column 1
ID Number
Row 2, Column 0
Row 2, Column 1
Drivers License Year
Row 3, Column 0
Row 3, Column 1
Drivers License Code
Row 4, Column 0
Row 4, Column 1
Full Name And Surname
Occupation
ID Number
Drivers License Year
Drivers License Code
MR
Row 0, Column 0
MRS/MS
Row 0, Column 1
MR
Row 1, Column 0
MRS/MS
Row 1, Column 1
MR
Row 2, Column 0
MRS/MS
Row 2, Column 1
MR
Row 3, Column 0
MRS/MS
Row 3, Column 1
MR
Row 4, Column 0
MRS/MS
Row 4, Column 1
1 of 5
2
Email* This field is required.
example@example.com
3
Relationship Status* This field is required.
Please Select
Please Select
Married
Divorced
Widowed
Single
Living with a Partner
4
Have you or has any member of your household had any application for insurance declined or insurance cancelled or renewal refused or not invited or had special conditions imposed* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
Have you or has any member of your Household been involved in any civil or criminal litigation in the past 5 years or have you any civil judgement against you* This field is required.
6
Full Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Security At Address* This field is required.
Yes
No
Burglar Guards on all opening window
Row 0, Column 0
Row 0, Column 1
Security Gates on all doors
Row 1, Column 0
Row 1, Column 1
Linked alarm
Row 2, Column 0
Row 2, Column 1
CCTV Cameras
Row 3, Column 0
Row 3, Column 1
Perimeter wall / Fence at least 1.8m high
Row 4, Column 0
Row 4, Column 1
Razor wire on wall / fence
Row 5, Column 0
Row 5, Column 1
Electric Fence on wall / fence
Row 6, Column 0
Row 6, Column 1
Burglar Guards on all opening window
Security Gates on all doors
Linked alarm
CCTV Cameras
Perimeter wall / Fence at least 1.8m high
Razor wire on wall / fence
Electric Fence on wall / fence
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
1 of 7
8
Do you currently have Insurance?:
Yes
No
9
Who is the underwriter* This field is required.
10
For how many years have you had insurance* This field is required.
11
Property Related* This field is required.
Yes
No
Will the property be unoccupied for more than 7 consecutive days in the first 30days of cover?:
Row 0, Column 0
Row 0, Column 1
Will the property be left unoccupied during working hours?
Row 1, Column 0
Row 1, Column 1
Will the residence be unoccupied for more than 60 consecutive days per year?:
Row 2, Column 0
Row 2, Column 1
Will the property be unoccupied for more than 7 consecutive days in the first 30days of cover?:
Will the property be left unoccupied during working hours?
Will the residence be unoccupied for more than 60 consecutive days per year?:
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
1 of 3
12
Please disclose all claims an losses in the last 5 years* This field is required.
Date of claim/loss
Type of claim/loss (i.e., Windscreen, Motor accident,motor theft, Lightning, fire, etc.)
Claim/loss amount
Loss 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Loss 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Loss 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Loss 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Loss 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Loss 1
Loss 2
Loss 3
Loss 4
Loss 5
Date of claim/loss
Row 0, Column 0
Type of claim/loss (i.e., Windscreen, Motor accident,motor theft, Lightning, fire, etc.)
Row 0, Column 1
Claim/loss amount
Row 0, Column 2
Date of claim/loss
Row 1, Column 0
Type of claim/loss (i.e., Windscreen, Motor accident,motor theft, Lightning, fire, etc.)
Row 1, Column 1
Claim/loss amount
Row 1, Column 2
Date of claim/loss
Row 2, Column 0
Type of claim/loss (i.e., Windscreen, Motor accident,motor theft, Lightning, fire, etc.)
Row 2, Column 1
Claim/loss amount
Row 2, Column 2
Date of claim/loss
Row 3, Column 0
Type of claim/loss (i.e., Windscreen, Motor accident,motor theft, Lightning, fire, etc.)
Row 3, Column 1
Claim/loss amount
Row 3, Column 2
Date of claim/loss
Row 4, Column 0
Type of claim/loss (i.e., Windscreen, Motor accident,motor theft, Lightning, fire, etc.)
Row 4, Column 1
Claim/loss amount
Row 4, Column 2
1 of 5
13
Full address of building requiring cover:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Building Replacement Value* This field is required.
15
Number of geysers* This field is required.
16
Size of geysers (Litres)
17
Do you have a solar geyser* This field is required.
Yes
No
18
Please Provide Solar Geyser Volume Capacity* This field is required.
19
Do you require cover for solar panels?* This field is required.
Yes
No
20
Please advise sum insured for solar panels* This field is required.
21
Roof Type* This field is required.
22
Wall Type* This field is required.
23
Power surge cover required (Excluding loadshedding)?* This field is required.If yes, what amount R 10 000, R 25 000, R 50 000, R 100 000 or R 250 000
24
Power surge cover required (Including Loadshedding)?* This field is required.If yes, what amount R 10 000, R 25 000, R 50 000, R 100 000 or R 250 000
25
Accidental damage cover required?* This field is required.If yes, what amount R 10 000, R 25 000, R 50 000, R 100 000 or R 250 000
26
Replacement sum insured required for household goods* This field is required.
27
Do you run a business from home:* This field is required.
Yes
No
28
Power surge cover required Excluding loadshedding* This field is required.If yes, what amount R 10 000, R 25 000, R 50 000, R 100 000 or R 250 000
29
Power surge cover required Including Loadshedding* This field is required.If yes, what amount R 10 000, R 25 000, R 50 000, R 100 000 or R 250 000
30
Accidental damage cover required* This field is required.If yes, what amount R 10 000, R 25 000, R 50 000, R 100 000 or R 250 000
31
Night time security* This field is required.
32
Day time security
33
Car hire required* This field is required.
34
Cover type Third party only Third party fire and theft and Comprehensive* This field is required.
35
Car hire engine size* This field is required.
Please Select
Please Select
Standard
Premium
Double cab 4x4
36
Car hire period 30, 60 or 90 days* This field is required.
37
Do you require credit shortfall* This field is required.
38
Bank for which interest should be noted* This field is required.
39
Vehicle registration number* This field is required.
40
Full make of vehicle* This field is required.
41
Year model* This field is required.
42
Vehicle colour* This field is required.
43
Full model of vehicle* This field is required.
44
Metallic* This field is required.
45
Vehicle usage* This field is required.
Please Select
Please Select
Domestic
Business (Business – seeing clients not carrying in goods)
46
Vehicle* This field is required.
Yes
No
Does the vehicle have any non-factory fitted modifications?:
Row 0, Column 0
Row 0, Column 1
Does the vehicle have any existing Damage?:
Row 1, Column 0
Row 1, Column 1
Is the registered owner of the vehicle the insured or the insured's spouse?:
Row 2, Column 0
Row 2, Column 1
Does the vehicle have any non-factory fitted modifications?:
Does the vehicle have any existing Damage?:
Is the registered owner of the vehicle the insured or the insured's spouse?:
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
1 of 3
47
Approved gearlock* This field is required.
48
Approved immobiliser* This field is required.
49
Locked garage or secured area* This field is required.
50
Tracking and recovery system* This field is required.
51
Day time security
52
Night time security* This field is required.
53
Car hire required
54
Cover type Third party only Third party fire and theft and Comprehensive
55
Car hire period 30 60 or 90 days
56
Car hire engine size
Please Select
Please Select
Standard
Premium
Double cab 4x4
57
Do you require credit shortfall
58
Bank for which interest should be noted
59
Vehicle registration number
60
Year model
61
Vehicle colour
62
Full model of vehicle
63
Full make of vehicle
64
Metallic
65
Vehicle usage
Please Select
Please Select
Domestic
Business (Business – seeing clients not carrying in goods)
66
Vehicle
Yes
No
Does the vehicle have any non-factory fitted modifications?:
Row 0, Column 0
Row 0, Column 1
Does the vehicle have any existing Damage?:
Row 1, Column 0
Row 1, Column 1
Is the registered owner of the vehicle the insured or the insured's spouse?:
Row 2, Column 0
Row 2, Column 1
Does the vehicle have any non-factory fitted modifications?:
Does the vehicle have any existing Damage?:
Is the registered owner of the vehicle the insured or the insured's spouse?:
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
1 of 3
67
Approved gearlock
68
Approved immobiliser
69
Locked garage or secured area
70
Tracking and recovery system
71
Day time security
72
Night time security
73
Car hire required
74
Cover type Third party only Third party fire and theft and Comprehensive
75
Car hire period 30 60 or 90 days
76
Do you require credit shortfall
77
Car hire engine size
Please Select
Please Select
Standard
Premium
Double cab 4x4
78
Bank for which interest should be noted
79
Vehicle registration number
80
Year model
81
Full model of vehicle
82
Full make of vehicle
83
Metallic
84
Vehicle colour
85
Vehicle usage
Please Select
Please Select
Domestic
Business (Business – seeing clients not carrying in goods)
86
Vehicle
Yes
No
Does the vehicle have any non-factory fitted modifications?:
Row 0, Column 0
Row 0, Column 1
Does the vehicle have any existing Damage?:
Row 1, Column 0
Row 1, Column 1
Is the registered owner of the vehicle the insured or the insured's spouse?:
Row 2, Column 0
Row 2, Column 1
Does the vehicle have any non-factory fitted modifications?:
Does the vehicle have any existing Damage?:
Is the registered owner of the vehicle the insured or the insured's spouse?:
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
1 of 3
87
Approved gearlock
88
Approved immobiliser
89
Locked garage or secured area
90
Tracking and recovery system
91
All risk Section NB: All items leaving the house must be specified to enjoy cover-items - such as laptops, cellphones, tablets, fablets and jewellery must be specified to enjoy cover - should these items not be specified there will be no cover even if they do not leave the house
Item
Amount
Serial Number
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
1
2
3
4
5
Item
Row 0, Column 0
Amount
Row 0, Column 1
Serial Number
Row 0, Column 2
Item
Row 1, Column 0
Amount
Row 1, Column 1
Serial Number
Row 1, Column 2
Item
Row 2, Column 0
Amount
Row 2, Column 1
Serial Number
Row 2, Column 2
Item
Row 3, Column 0
Amount
Row 3, Column 1
Serial Number
Row 3, Column 2
Item
Row 4, Column 0
Amount
Row 4, Column 1
Serial Number
Row 4, Column 2
1 of 5
92
Other goods
Should be Empty: