Personal Short Term Insurance

Personal Particulars
Title:
Initials: Surname:*
Occupation: Identity Number:*
Address Line 1:* Address Line 2:
Address Line 3: Post Code:*
Home Phone Number: Work Phone Number:
Cellular Phone:* Fax Number:
Email Address:* How would you like to be contacted:
Current Insurance Company:
 
Household Contents Section
Residence Type: Roof Construction:
Burglar Bars: Security Gates:
Alarm: Yes    No Alarm Type (if applicable):
24hr Controlled Access: Yes    No Contents Value/Sum Insured:
 
All Risks
General Unspecified (Minimum R 5,000):
Specified Items: (car radios, contact lenses, sunglasses and cellphones are not covered unless specified)
Details: Amount:
1. R
2. R
3. R
4. R
5. R
6. R
7. R
8. R
9. R
10. R
 
Motor Vehicles
Vehicle 1
Full description of vehicle: Year of vehicle:
Mileage: Condition:
Insured amount: Use: Private    Business
Cover: Comprehensive
Third party fire and theft
Third party only
Vehicle security system: Alarm
Gearlock
Tracking device
Immobiliser
Radio (make,model,value): Registered owner:
Name of regular driver: Driver occupation:
Additional Remarks:
 
Vehicle 2
Full description of vehicle: Year of vehicle:
Mileage: Condition:
Insured amount: Use: Private    Business
Cover: Comprehensive
Third party fire and theft
Third party only
Vehicle security system: Alarm
Gearlock
Tracking device
Immobiliser
Radio (make,model,value): Registered owner:
Name of regular driver: Driver occupation:
Additional Remarks:
 
Vehicle 3
Full description of vehicle: Year of vehicle:
Mileage: Condition:
Insured amount: Use: Private    Business
Cover: Comprehensive
Third party fire and theft
Third party only
Vehicle security system: Alarm
Gearlock
Tracking device
Immobiliser
Radio (make,model,value): Registered owner:
Name of regular driver: Driver occupation:
Additional Remarks:
 
Vehicle 4
Full description of vehicle: Year of vehicle:
Mileage: Condition:
Insured amount: Use: Private    Business
Cover: Comprehensive
Third party fire and theft
Third party only
Vehicle security system: Alarm
Gearlock
Tracking device
Immobiliser
Radio (make,model,value): Registered owner:
Name of regular driver: Driver occupation:
Additional Remarks:
Security Code* Change Image