Home, Auto, Renters, and Life Insurance Request for quote
Please fill the form accurately for better assistance
Person & Contact Details
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of insurance are you looking for?
Homeowners
Auto
Renters
Life Insurance
Bundle
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Existing Insurance
We may require a copy of your current insurance policy
Are you currently insured?
*
Yes
No
Existing Insurance Policy Number
Current Premium
Current Insurer
Number of Years Uninterrupted Insurance Cover (Required to Quote)
*
Less Than 1 Year
1 Year
2 Year
3 Year
4 Year
5 Years
More Than 5 Years
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Vehicle Details
We require some information about your vehicle to do an accurate quote.
Make of Vehicle
*
Example: Ford / Toyota / Volkswagen etc
Model of Vehicle
*
Example: Ford Eco Sport
Year of Vehicle Model
*
VIN Number
*
Color of Vehicle
*
Regular Driver Full Name
*
Date Issued Driver License
*
-
Month
-
Day
Year
Date
Driver's License Number
*
Is The Vehicle Financed?
*
Yes
No
Which creditor did you finance your vehicle with?
Outstanding Amount Owed on Vehicle
*
Is your Vehicle used for Private or/and Business?
*
Private only
Business only
Private and Business
Please Select- Security in Vehicle
*
Alarm
Tracking
Immobilizer
None
Where is your vehicle parked at night?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you require car rental?
*
Yes
No
Have you had any claims in the past 3 years?
*
Yes
No
Do you need to insure extras? Please add what extras you would like to insure, with the value.
*
Example: Radio R 5 000
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Home Details
We require some information about your building to do an accurate quote for building insurance.
Please select your type of home
*
Single-Family Home
Townhouse
Flat (Ground Floor)
Flat (Upper Level)
Farm
Semi Detached
Type of construction
*
Example: Face Brick Wall / Plastered Wall / Wood Cabin
Do you have a Asphalt roof?
*
Yes
No
Is your roof pitched or flat?
*
Pitched Roof
Flat Roof
Number of Rooms
Do you have a swimming pool?
Yes
No
Total value of building to be insured
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Home Content Details
We require some information about your home content to do an accurate quote.
Are you residing at the property?
*
Yes
No
Is there any construction happening on/or around your premises?
*
Yes
No
Is your home occupied during the day?
*
Yes
No
Which date did you take occupation at the property
-
Month
-
Day
Year
Please select what is applicable to your home
*
Bulgar bars on all opening windows
Bulgar bars on all fixed windows
Security gate on all external doors
Security gate on all sliding doors
Linked alarm with armed response
Linked alarm without armed response
Access control with security guard
Access control without security guard
24 hour guard patrol on premises
Electric fence surrounding the property
Total value of all your home content to be insured
*
Example: TV / Couch / Fridge / Washing Machine etc
Total value of all your jewelry to be insured
Total value of your cellphone to be insured
Total value of your Laptop and Computer to be insured
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Renters Insurance
Name on the lease
*
First Name
Last Name
Move-In Date
*
-
Month
-
Day
Year
Date
Estimated Value of Personal Belongings
*
Primary Coverage Need
*
Personal Property Coverage
Liability Coverage
Both Personal Property and Liability
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Life Insurance
Type of life insurance you are looking for
*
Term Life
Whole Life
Universal Life
Index Universal Life
Variable Universal Life
I don't know
How much life insurance are you looking for?
*
$10,000
$15,000
$25,000
$50,000
$100,000
$250,000
$500,000
$1,000,000
Are you looking to cover yourself or someone else?
*
Myself
Someone Else
How is this person related to you?
*
It's Me
Spouse
Parent
Dependent
Off-spring
Business Partner
How much total life insurance do you/they currently have?
*
If none, type "None" or "0"
Who would you like to list for a beneficiary?
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ALMOST Done!
Please upload any documents that might be useful. For example a copy of current or former insurance statement
Current Policy Schedule
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