Quotation for Motor Insurance
 

Please enter your details below as requested to get an quotation on Motor insurance. 

 

 
  Please complete the fields below:
     
  Title and Initials:
  Surname:
  Cellular nr:
  Nationality:
  ID or Passport nr:
  Drivers Licence Code:
  Date of first licence issue:
  Licence Restrictions (eg: have to drive with glases):
  Occupation:
     
  Please select your marital status:
     
  Married
  Single
  Divorced
  Separated
  Widowed
  Living together
     
  Previous insurance details:
     
  Name your current or previous insurance:
  How long did you have uninterrupted:
  List previous claims (paid or not paid):
  If not paid, supply reason:
     
  What type of insurance cover are you applying for:
     
  Comprehensive
  Third party fire and theft
  Third party only
     
  Where will the Vehicle be parked during the day:
     
  Access controlled area
  Open parking
     
  Where will the Vehicle be parked at night:
     
  Locked Garage
  Behind a Locked gate
     
  What will the Vehicle be used for:
     
  Business
  Private
     
  Is the vehicle under finance or paid up:
     
  Financed
  Paid up
     
  Details of the Vehicle:
     
  Year Model:
  Make and Model:
  Engine Capacity:
  Paint - Metallic or Gloss:
  Any Extras:
  Security of the vehicle(eg: immobilizer alarm, tracking device, gear lock):
     
  Details of the regular driver (only complete this section if the regular driver is not the applicant for the quotation):
     
  Initials:
  Surname:
  ID or Passport nr:
  Licence code:
  Licence restrictions:
  Date of first licence issue:
  Any previous insurance claims:
  Occupation or Student:
     
  Risk address:
     
  Street and house nr:
  Suburb:
  City:
  Province: