Short Term Insurance Application

Personal Details

Name & Surname

ID Number

Email Address(Required)

Contact No(Required)

Office Contact No

Marital Status

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)

Are you insolvent, under administration or has any Insurance Provider ever cancelled your policy?

Are you currently insured?

How long have you been insured for?

What are you currently paying?

Have you had any claims or losses in the last 5 years?

Do you have a current insurance schedule?

Upload Schedule

Drop files here or

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 provide details of the claims or losses

Was the claim paid?

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?

Does the property have remote access control?

Does the property have electric fencing, barbed wire or palisade spikes?

Are there burglar bars on all windows?

Are there security gates on all access doors?

Do you have an alarm?

Is it linked to an armed response?

Is the property within 100m of any body of water?

Is there any other security you would like to note?

Please describe additional security

Is there any credit/loan agreement on the building?

Vehicle Details

Vehicle Usage Type

Private use: Refers to using a vehicle for personal or family purposes, such as commuting, errands, and leisure. It does not include any work-related activities.
Business use: Refers to using a vehicle for work-related purposes, such as making deliveries, attending meetings, or transporting goods or clients. This applies when a vehicle is essential to carrying out business activities beyond just commuting.

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?

Any non standard accessories (eg rims, smash & grab etc)

Any existing damage to the vehicle?

Please describe the damage

Is the vehicle financed?

With which bank?

Who is the registered owner of the vehicle?

ID Number of Registered Owner

Full names of Registered Owner

Occupation / Job Title of Registered Owner

Marital Status of Registered Owner

Who is the Regular Driver of the vehicle?

ID Number of Regular Driver

Full names of Regular Driver

Occupation / Job Title of Regular Driver

Marital Status of Regular Driver

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

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?

Is there anything else you would like to specify (bicycles, trailers, caravans etc)

Description of item

Value of item