Take 2 minutes to fill in the form and START SAVING !!! Please note : It is very important to fill this form in as thoroughly  as possible.  All questions asked is relevant and needed to supply a correct quotation.     Surname Initial Title Select Mr HonMrsMissMsDrProf ID Number Preferred Language Select English Afrikaans Residential Suburb and town.    eg. Morningside,    Johannesburg Postal code     Tel no & code Cellphone E-mail     Marital status Married Select SingleDivorcedWidowedPartneredSeparated Are you currently insured ? YesNoNever had insurance before Select Have you been insured during the last 30 days Yes Select No     Current or previous insurance companies SantamMutualandFederalOutsuranceAuto and GeneralSA EagleDial DirectNever been insuredHollard InsuranceLion of AfricaBudget InsuranceOtherNew NationalUnity Insurance How long in total? Never been insuredless than 1 year1 to 2 years2 to 3 years3 to 4 years4 to 5 years5 to 6 years6 to 7 yearsmore than 7 years Did you have any claims in the last 5 years No claims1 Claim2 Claims3 Claims4 or more claims Detail of claims and value and date of claim(s) (eg. R8000 ) (if any )         House Contents Details Type of residence  Freestanding houseTownhouse - not in security complexFlat - On ground floorFlat - Above ground floor Insured amount for house contents.   R 100 000 minimum Construction of the walls of the home BrickWoodOther Type of roof TilesIBR - Zinc roof.Thatchroof with ThachsafeThatchroofOther   Security at your house. Tick one or more blocks        Burglar bars in front of all opening windows                         Select Yes No        Safety gates at all outside doors, sliding doors included   Select Yes No          Alarm system with armed response by                                  Select Yes No        a professional security company                                                    Alarm system linked to a monitoring room of a                         security company with no armed response                           Select Yes No          Is the perimiter walls secured with electric fencing            Select Yes No          Do you stay in a complex with 24 hr security guards        on the premises, a boomed entrance with security        checking and electric fencing on the perimiter walls           Select Yes No   Date you moved in at this address              How many years have you stayed at this addres without a claim ? 01234567More than 7     all risks cover  : Clothing and personal possessions Unspecified items : Insured amount              ALL RISKS : Specified items Eg. Cellphones, laptop computers and jewelry of value of more than R 1000 Item 1 description              ReplacementValue: Item 2 description              ReplacementValue: Item 3 description              ReplacementValue: Item 4 description              ReplacementValue: Item 5 description              ReplacementValue:     BUILDING INSURANCE This building is used as  my.... Main residenceHoliday residenceOther residence Residential suburb and town Postal code  Construction of the walls of the home Brick Select WoodOther Type of roof TilesIBR - Zinc roof.Thatchroof with ThachsafeThatchroofOther Would you need cover for landslide and subsidence Select YesNo Insured amount      CAR INSURANCE VEHICLE NO.1 Year of manufacture 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005 2006 2007 Make of car Select AudiB M WChevroletChryslerCitroënColtDaewooDaihatsuFiatFordHondaHummerHyuandaiIsuzuJaguarJeepKIALand RoverLexusMahindraMazdaMercedes BenzM GMINIMitsubishiNissanOpelPeugeotPorscheRange RoverRenaultRoverSAABSmartSsyangYongSubaruSuzukiTATAToyotaUnoVWVolvo Model description  eg. Toyota Corolla 160i GLE with aircon Value Overnight parking Select Locked garageIn yard - Behind locked gatesIn yard - No gatesCarport in secure complexIn street Vehicle cover Comprehensive cover3rd Party, Fire and Theft3rd Party onlyPrivate useBusiness use Radio cover : Is the carradio factoryfitted    YesNo Value of radio     Vehicle security Factory fitted Immobiliser        Yes Select No   Vesa approved gearlock            Yes Select No  Is the vehicle equipped with a anti hi-jacking device   Yes Select No   Tracking devices Is the vehicle equipped with a tracking device    Yes Select No   If yes, what type or trademark eg. Tracker Details of the most regular driver When was this person issued with a drivers license? Just give a rough estimate !!     Claim-free years  of this vehicle     01234567 or more years     VEHICLE NO.2 Year of manufacture 19801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005 2006 2007 Make of car Select AudiB M WChevroletChryslerCitroënColtDaewooDaihatsuFiatFordHondaHummerHyuandaiIsuzuJaguarJeepKIALand RoverLexusMahindraMazdaMercedes BenzM GMINIMitsubishiNissanOpelPeugeotPorscheRange RoverRenaultRoverSAABSmartSsyangYongSubaruSuzukiTATAToyotaUnoVWVolvo Model description  eg. Toyota Corolla 160i GLE with aircon Value Overnight parking Locked garageIn yard - Behind locked gatesIn yard - No gatesCarport in secure complexIn street Vehicle cover Comprehensive cover3rd Party, Fire and Theft3rd Party onlyPrivate useBusiness use Radio cover : Is the carradio factoryfitted    YesNo Value of radio     Vehicle security Factory fitted Immobiliser      Yes Select No   Vesa approved gearlock        Yes Select No  Is the vehicle equipped with a anti hi-jacking device   Yes Select No   Tracking devices Is the vehicle equipped with a tracking device    Yes Select No   If yes, what type or trademark eg. Tracker Details of the most regular driver When was this person issued with a drivers license? Just give a rough estimate !!     Claim-free years  of this vehicle     01234567 or more years     ADDITIONAL INFORMATION : Here you can give us notes of extra items or maybe there is extra information that you might think is relevant to this quotation