Home & Auto Insurance Request
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
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Existing Insurance
Tell us about your current coverage so we can compare and customize your quote
Are you currently insured?
*
Yes
No
Auto Current Insurer
Home Current Insurer
Auto Current Premium
Home Current Premium
Have you had at least 6 months of continuous auto insurance?
*
Yes
No
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Vehicle Details
Help us understand your vehicles so we can deliver the most accurate and competitive quote.
Year of Vehicle Model
*
Make of Vehicle
*
Example: Ford / Toyota / Volkswagen etc
Model of Vehicle
*
Example: Ford Eco Sport
Vehicle Registration Number
*
Regular Driver Full Name
*
Is The Vehicle Financed?
*
Yes
No
Which creditor did you finance your vehicle with?
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
Do you require car hire?
*
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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Property Details
Provide a few details about your property so we can prepare an accurate homeowners quote.
Please select your type of home
*
Single-Family House
Townhouse
Condominium (Condo)
Mobile Home / Manufactured Home
Apartment
Duplex / Two-Family Home
Multi-Family Home (3+ units)
Other (please specify)
If other, please specify
*
Example: Log Cabin
Type of construction
*
Example: Solid Brick, Wood Frame
Is your roof pitched or flat?
*
Pitched Roof
Flat Roof
Number of Rooms
Number of Geysers
Do you have a swimming pool?
Yes
No
Do you have a trampoline?
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
Purchase Date of 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
How do you pay your homeowners insurance—through escrow or on your own?
*
Escrow
On your own
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Upload your current policy
Got a current policy? Upload it here for a quick review.
Current Policy Schedule
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