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Burglary Claim Application Form Quick Quote

 

PROPOSAL FOR INSURANCE QUOTATION
A.Personal Information:
Title: *
First Names: *
Surname: *
E - Mail: *
ID Number: *
Tel. H
Cell:
* required fields
B. Home Address:
Post code:
C: Building / Construction Information
Please check relevant items:
Thatch Roof
yes no
Value of building:
R.
Value of house contents:
R.
F. Security Information:
Alarm with armed reaction yes no
Burglar bars in front of all opening windows yes no
Security gates in front of all outside doors yes no
Remote controlled entrance yes no
G. Specified Items (eg. jewelry, cellphones, cameras etc - Any item out of the house)
Item: Value:
1.
R.
2.
R.
3.
R.
H. Vehicle Information 1 (Motorcycle, caravan/trailer, watercraft)
Registered owner:
 
Year of model:
 
Make:
Model:
Value: R.
Use:
Car hire:
yes no
Gearlock:
yes no
Immobiliser (must have VESA cert.):
yes no
Satellite tracking system:
yes no
Value of radio:
 R.
Vehicle Information 2 (Motorcycle, caravan/trailer, watercraft)
Registered owner:
 
Year of model:
 
Make:
Model:
Value: R.
Use:
Car hire:
yes no
Gearlock:
yes no
Immobiliser (must have VESA cert.):
yes no
Satellite tracking system:
yes no
Value of radio:
 R.
Vehicle Information 3 (Motorcycle, caravan/trailer, watercraft)
Registered owner:
 
Year of model:
 
Make:
Model:
Value: R.
Use:
Car hire:
yes no
Gearlock:
yes no
Immobiliser (must have VESA cert.):
yes no
Satellite tracking system:
yes no
Value of radio:
 R.
I. Previous / Current Insurance:
Did you have previous insurance?
yes no
How long:
Did you have any claims in the last 5 years?
 yes no
Date of claim
Description:
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