Name
Contact Numbers
Email address
ID Number
Risk Address
Area Code
Marital Status
Have you had uninterrupted insurance for the last 5 years?
If not, how long?
Any incidents whether insured or not?
Current Premium
Type of residence: Cluster / House / Townhouse / Flat
Burglar bars on opening windows?
Security gates on all doors?
Do you have a linked alarm?
Do you have an electric fence?
Do you stay in a secure complex?
Is your home occupied during the day?
Are you co-residing?
Is this the main residence?
Are you currently insured on the house contents?
Have you had contents insurance for the last 5 years?
Any incidents whether insured or not in 5 years?
Cover Required: Full cover, Fire and perils only (excluding theft)
Value of contents?
What are the walls constructed of: Brick & plaster / Asbestos / Wood
What is the roof constructed of: Tile / Zinc / Iron / Slate / Thatch
Are you co-residing: Yes / No
Is this the main residence: Yes / No
Are you currently insured on the building/home?
Have you had building insurance for the last 5 years?
Value of home?
Clothing and personal effects to the value of:
Camera's to the value of:
Laptops to the value of:
Jewellery to the value of:
Spectacles/Sun specs to the value of:
Outdoor equipment to the value of:
Cell phones to the value of:
Bicycles to the value of:
Ipods/Audio equipment to the value of:
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