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Have you as the Insured; or your spouse, or any person that may be living with you, or any other person that may at anytime drive any of the vehicles stated in this policy in any capacity?
Registered Owner's ID & Relationship to Insured
Regular Driver's ID & Relationship to Insured
Occupation of Driver
Marital Status of Driver
Year Drivers License Obtained
Have you completed any defensive driving course?
Will anyone else drive the vehicle?
Name of Driver
Driver's ID & Relationship to the Insured
Type of Use
Average kilometres traveled per month
Type of Cover
Security Fitted in Vehicle
Any extras fitted & value
Do you require these extras to be insured?
Car radio cover required?
If Yes, please provide further details
Is the vehicle modified/converted?
Address where vehicle is kept at night
Is the vehicle in a locked garage or behind locked gates at night?
Address where vehicle is kept during the day
What security is in place at the risk address during the day?
(Purchase Invoice Required)
Do you require car hire?
Has the vehicle been purchased through:
Interest of Financial Institution:
(Purchase invoice required)
Are you insured on any other vehicle insurance at the moment?
Please advise the cancellation date of the above policy
Have you had continuous insurance in the last five years?
If no, please provide further details
Reason for Cancellation:
Have you or any other drive of the vehicle/s ever had their drivers license endorsed or cancelled?
If yes, please provide further details
Please provide details of any claims or losses suffered by you during the past five years, whether insured on any policy or not
Do you require the insurance?
The age limits for acceptance under this section are 18 to 75 years
PERSONS TO BE INSURED
Name & Surname
Relationship to the insured
(Maximum not to exceed death benefit)
Temporary Total Disablement
(Maximum 52 Weeks)
(Maximum R10 000/week)
(Maximum R10 000)
Please give full details of all injuries which any of the persons to be insured have incurred (giving dates & duration)
Please provide any details of any claims or losses suffered by you during the past five years:
In respect of any claim consequent upon your death, we will pay the benefit to the beneficiary nominated by you and named in the schedule
Please provide a detailed description of each selection in the fields provided in order to receive the most accurate quoting experience.
Should more information be required, we will contact you
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