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Home
About
Services
Physical Asset Insurance
Medical Cover
Life & Disability insurance
Investments
Bespoke financial advice
Media
Contact
Home
About
Services
Physical Asset Insurance
Medical Cover
Life & Disability insurance
Investments
Bespoke financial advice
Media
Contact
Menu
Home
About
Services
Physical Asset Insurance
Medical Cover
Life & Disability insurance
Investments
Bespoke financial advice
Media
Contact
Motor Vehicle Insurance
Capture your details and we’ll get an expert to respond with some options and guidance for you.
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
Would you like to attach your existing policy? (If you attach an existing policy you can reduce the amount of information we need to capture.)
Please select…
Yes
No
Please attach your current policy schedule
Please attach a copy of your ID
Who is your current insurance company?
What is your current policy number?
What is your current insurance premium?
For how many years have you been insured?
Your insurance company prior to current (if any)?
PERSONAL DETAILS
Insured First Name
Insured Surname
Gender
Please select…
Male
Female
Other
Nationality
ID Number
Occupation
Residential Address
Postal Address
Cellphone Number
Email Address
Marital Status
Please select…
Married
Co-Habit
Divorced
Widowed
Single
Are you co-insured (i.e. another person with an interest in insuring this asset)?
Please select…
Yes
No
Co-Insured Name & Surname
Co-Insured Gender
Please select…
Male
Female
Co-Insured ID Number
Co-Insured Occupation
Has an insurance company ever cancelled your entire policy or part of a policy?
Please select…
Yes
No
Has special conditions ever been attached to your Insurance?
Please select…
Yes
No
CLAIMS
Please include detail of any short term claims you've had in the last 5 years
Date of Claim
Type of Claim (Vehicle, Home, Assets, etc)
Description
Amount paid out by your insurance company
Have you had another claim in the last 5 years?
Please select…
Yes
No
Date of Claim
Type of Claim (Vehicle, Home, Assets, etc)
Description
Amount paid out by your insurance company
Have you had another claim in the last 5 years?
Please select…
Yes
No
Date of Claim
Type of Claim (Vehicle, Home, Assets, etc)
Description
Amount paid out by your insurance company
VEHICLE DETAILS
Make
Model
Colour
Year
Registration No.
VIN No.
Engine No.
VEHICLE OWNER AND FINANCE INFORMATION
DRIVER DETAILS
Regular Drivers Name
Regular Drivers ID Number
Drivers licence code (E,EB)
Drivers licence date of first issue
Registered Owners Name
Registered Owners ID Number
Finance House
Finance A/C No.
ADDITONAL DETAILS
Extras on the car
Is there signage on the vehicle?
Please select…
Yes
No
Value of Signage
Where is the vehicle parked at night?
Where is the vehicle parked during the day?
Security
Immobiliser
Tracker
Gear lock
Other
None
ADDITIONAL DETAILS
Do you want Waiver of Excess? (i.e. no excess paid in the event of a claim)
Please select…
Yes
No
Do you require car hire? GROUP B economy hatchback (30 days unless otherwise specified)
Please select…
Yes
No
Do you require credit shortfall cover?
Please select…
Yes
No
Do you have a residual? (i.e. a balloon paymenton your vehicle finance agreement)
Please select…
Yes
No
Type of comprehensive cover?
Please select…
Private use (social, domestic & pleasure)
Business use (to see clients, but NOT to carry goods)
Terms and conditions
By ticking, you are confirming that you have read, understood and agree to
Life Current terms and conditions.
Submit