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Request a quote

Personal Details :

Name: * required

Surname: * required

ID Number (13 characters): * required

Marital Status: Divorced Married Single Widowed

Cell number: * required

Email address: * required

Address:

(Suburb)
(Postal Code)

Uninterrupted Comp Insurance: Insurance in last 0-12 months
Insurance in last 13-24 months
Insurance in last 25-36 months
Insurance in last 37-48 months
Insurance in last 48-60 months

Vehicle :

Present Comp Vehicle Insurance: Yes
No
No - But drives Company Car
No - But had in last 39 days
No - But Insured on Spouse's Policy
No - But own Vehicle on Parents Policy

Year Model:    Make:   Model:

Owner:

Usage: Business
Private

Cover: Comprehensive
Third Party Fire & Theft
Third Party
Tracker: Tracker Device in Vehicle
Would like a quote on a Tracking
      Device
 

Year Licence First Issued:

Licence Code: B C C1 EB EC EC1

Would you like to include car hire: Yes No

If you have another vehicle you would like to insure please click on
I want to insure more than one vehicle

Household Contents :

Value of Home Contents:

Suffered Burglary / Loss at risk address: Yes No

Alarm Status: Alarm with 24 Hour Armed Response
Alarm with No Armed Response
None

Burglar Bars: All Opening Windows
All Windows
Some Windows
None

Security Gates: All Doors
Some Doors
None

Building :

Current Building Value:

Is there any other item you would like to insure ?

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Spam verification: * required