Clone of Vehicle Insurance Application Form PPM

  • Household Contents & Vehicle Insurance Application Form

    Please fill out the form to apply for vehicle insurance.
  • Occupational category
  • Marital Status
  • Title
  • Format: (000) 000-0000.

  • Vehicle Section

  • Date of Purchase*
     - -
  • What cover do you require?
  • Value basis for settlement
  • Is this a rebuilt
  • Has the vehicle’s performance been enhanced in any way?
  • Is this a rebuilt?
  • Type a question
  • Daytime parking security :
  • Overnight parking security:
  • If vehicle is kept in locked garage, is it electronically locked?
  • Do you require optional cover?
  • Vehicle use:
  • Include hail cover if comprehensive
  • If financed through which bank
  • Does the vehicle have metallic paint?
  • Is the vehicle financed?
  • Does the vehicle have an approved tracking device?
  • Do you currently have vehicle insurance?*
  • Are you or any business entities you have an interest in or any person you intend covering under this policy currently under administration or debt review?
  • Have you or anyone you intend covering under this policy been sequestrated or has a company that you or anyone you intend covering under this policy been liquidated in the last 5 years?
  • Has any insurer ever cancelled your insurance, applied special terms or refused a quotation?

  • Contents Section

  • Safety Features on premises
  • Type of property
  • Type of residence
  • Building use
  • Area
  • Type of geysers
  • Boundary wall
  • Is this a commune
  • Building Wall construction
  • Building Roof construction
  • Is there a thatch roof structure more than 15% of the size of the main building
  • Do you have surge protection installed
  • Building situated within 100m of a water body?
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