INSURANCE QUOTATION

 

The information submitted below is strictly confidential and will be viewed only by the intended recipient in order for you to receive your free quotation.

       

        Please feel free to add as many items as possible to this quotation and also add your comments in         the provided area.  This will make it easier for me to give you a proper quotation, and you can add         or remove whatever you feel is not appropriate.

     Personal Details

        First Name:                     Last Name:         

        Street Address:     

        ID Number:        

        Contact Details

        Tel Home:                     Tel Work:           

        Cell:                               E-Mail:                

        Current Insurance Information         NCB - No Claim Bonus

        Please mark whether the vehicle is used for business or private use.

        Current Insurer:   

        House Contents:  R            NCB:    Yes  No 

        CAR i   - Make: Model: Year: Value: NCB: Bus.: Priv.:

        CAR ii  - Make: Model: Year: Value: NCB: Bus.: Priv.:

        CAR iii - Make: Model: Year: Value: NCB: Bus.: Priv.:

        Security

        Car i    -  Immobilizer:     Yes No Gearlock:   Yes No   Tracker:  Yes No Other 

        Car ii  -   Immobilizer:     Yes No Gearlock:   Yes No   Tracker:  Yes No Other 

        Car iii -   Immobilizer:     Yes No Gearlock:   Yes No   Tracker:  Yes No Other 

        Trailer:            R  

        Caravan:         R   

        Motor Cycle  R   

        Specified Items

        Please list all other items of value e.g. camera's, jewelry etc.

        i   Item       Value  R 

        ii  Item       Value  R 

        iii Item      Value  R  

        iv Item      Value  R  

        v  Item      Value  R  

        Comments - Enter your comments in the space provided below: