INSURANCE QUOTATION
The information submitted below is strictly confidential and will be viewed only by the intended recipient in order for you to receive your free quotation.
Please feel free to add as many items as possible to this quotation and also add your comments in the provided area. This will make it easier for me to give you a proper quotation, and you can add or remove whatever you feel is not appropriate.
Personal Details
First Name: Last Name:
Street Address:
ID Number:
Contact Details
Tel Home: Tel Work:
Cell: E-Mail:
Current Insurance Information NCB - No Claim Bonus
Please mark whether the vehicle is used for business or private use.
Current Insurer:
House Contents: R NCB: Yes No
CAR i - Make: Model: Year: Value: NCB: 0 1 2 3 4 5 6 Bus.: Priv.:
CAR ii - Make: Model: Year: Value: NCB: 0 1 2 3 4 5 6 Bus.: Priv.:
CAR iii - Make: Model: Year: Value: NCB: 0 1 2 3 4 5 6 Bus.: Priv.:
Security
Car i - Immobilizer: Yes No Gearlock: Yes No Tracker: Yes No Other
Car ii - Immobilizer: Yes No Gearlock: Yes No Tracker: Yes No Other
Car iii - Immobilizer: Yes No Gearlock: Yes No Tracker: Yes No Other
Trailer: R
Caravan: R
Motor Cycle R
Specified Items
Please list all other items of value e.g. camera's, jewelry etc.
i Item Value R
ii Item Value R
iii Item Value R
iv Item Value R
v Item Value R
Comments - Enter your comments in the space provided below:
