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

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?

Do you have any previous insurance claims?(Required)

Claims History(Required)

Claim Type

Amount

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)

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?

All Risk Items

Please list all your all risk items

Description of Item

Value of Item

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?

* If the property has a thatched roof, a Thatch Questionnaire will be required and will apply accordingly.

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?

Finance House

Vehicle Details

Please add a vehicle

Vehicle Make (eg Volkswagen)	Vehicle Model (eg Polo Vivo Comfortline 1.6)	Vehicle Registration No	Vehicle Year (eg 2010, 2015 etc)	Actions

There are no Vehicles.

Confirmation of information

I hereby confirm that all information provided in this document is true, accurate, and complete to the best of my knowledge. I understand that any incorrect, incomplete, or misleading information may affect the validity of this application or any related agreement.