Home Insurance Form

Full Name:

Title

ID Number:

Marital Status

Employment Status

Email Address:

Work Telephone:

Cell Number:

Home Address:

Risk Home Address:

Insured Age:

House Description:

Area Situated

Is this a holiday home?

Is theft cover included?

Type of cover

Is the home near open fields?

Are you a pensioner?

Is the roof thatched?

Is the home in secured complex?

Does the home have an alarm?

If “Yes to the above, is the alarm linked to armed response?

Going away in next 30 days?

Non-standard construction?

Burglar bars on opening windows?

Security gates on external doors?

Have you previously had Insurance?

If Yes, with which companies?

Have you ever claimed from insurance?

If Yes, how many years have passed since you have submitted a claim?

Car Year:

Car Make:

Car Model:

Car's Value:

Is vehicle insured currently?

Name of Driver:

Birth date of Driver:

Radio insured amount (if applicable)

Insurance type

Vehicle use

Address where vehicle is kept overnight

Type of parking

Driver’s License code:

Date license issued:

Tracking device installed:

Immobiliser fitted:

Rebuilt/customised vehicle?

The Driver is

If there are vehicle accessories, please specify

Have you ever claimed from insurance?

If “Yes” to the above, how many years have passed since you have submitted a claim?

If applicable, please list claims/losses and values for the past 5 years

Trading Hours: Mon-Thu (08:00-16:30), Fridays (08:00-16:00) | After Hours: 555-555-5555

COMBINED INSURANCE