Personal Details
Name & Surname
ID Number
Email Address
Contact No
Office Contact No
Marital Status
Single
Married
Divorced
Widow / Widower
Job Title / Occupation
Physical Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
ITC Check
(Required)
Do you give us permission to complete a quote for you with a verification on ITC? (Credit Check)
What cover are you looking for?
Cover options
Building
Home Contents
Vehicle
Would you like to add all risk items (jewellery, cell phones, laptops, etc)
Please select
Yes
No
Are you insolvent, under administration or has any Insurance Provider ever cancelled your policy?
Please select
No
Yes
Are you currently insured?
Please select
Yes
No
How long have you been insured for?
What are you currently paying?
Have you had any claims or losses in the last 5 years?
Please select
No
Yes
Do you have a current insurance schedule?
Please select
Yes
No
Upload Schedule
Drop files here or
Select files
Max. file size: 8 MB.
How long have you had uninterrupted insurance?
Have you had any claims or losses in the last 5 years?
Please select
No
Yes
Please provide details of the claims or losses
Was the claim paid?
Yes
No
What is the amount that was paid?
Building / Contents
Value of building / contents
Roof Construction (eg tile, corrugated iron, asbestos etc)
Wall Construction (eg brick, concrete, wood etc)
Is there a swimming pool or thatch on the property?
All Risk Items
Description of item
Value of item
Security Questions
Do you have a perimeter wall around the premises of more than 1.8m in height?
Please select
Yes
No
Does the property have remote access control?
Please select
Yes
No
Does the property have electric fencing, barbed wire or palisade spikes?
Please select
Yes
No
Are there burglar bars on all windows?
Please select
Yes
No
Are there security gates on all access doors?
Please select
Yes
No
Do you have an alarm?
Please select
Yes
No
Is it linked to an armed response?
Please select
Yes
No
Is the property within 100m of any body of water?
Please select
Yes
No
Is there any other security you would like to note?
Please select
Yes
No
Please describe additional security
Is there any credit/loan agreement on the building?
Please select
Yes
No
Vehicle Details
Vehicle Year (eg 2010, 2015 etc)
Vehicle Make (eg Volkswagen)
Vehicle Model (eg Polo Vivo Comfortline 1.6)
Vehicle Color
Do you have a tracking device?
Please select
Yes
No
Any non standard accessories (eg rims, smash & grab etc)
Any existing damage to the vehicle?
Please select
Yes
No
Please describe the damage
Is the vehicle financed?
Please select
Yes
No
With which bank?
Who is the registered owner of the vehicle?
Please select
Me
Somebody else
ID Number of Registered Owner
Full names of Registered Owner
Occupation / Job Title of Registered Owner
Marital Status of Registered Owner
Please select
Single
Married
Divorced
Widow / Widower
Who is the Regular Driver of the vehicle?
Me
Somebody else
ID Number of Regular Driver
Full names of Regular Driver
Occupation / Job Title of Regular Driver
Marital Status of Regular Driver
Please select
Single
Married
Divorced
Widow / Widower
Regular driver licence code?
Date of regular driver first issue of licence card?
Where will the vehicle be parked at night?
Same as previous
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Overnight is the vehicle parked
Please select
In a locked garage
Behind locked gates
Street
Access controlled area
Where will the vehicle be parked during the day?
Same as previous
Suburb
City
ZIP / Postal Code
During the day where is the vehicle parked?
Please select
Behind locked gates
Street
Access controlled area
Is there anything else you would like to specify (bicycles, trailers, caravans etc)
Please select
No
Yes
Description of item
Value of item
