VEHICLE QUOTE
 
vehicle insurance  
     
  Vehicle Quote        
         
 

Please take a moment to complete our online form. Once received, a consultant will obtain quotes from our panel of insurers and contact you via e-mail and telephone. All information submitted will be kept private & confidential (see our Privacy Policy).

 
 
 
 
PERSONAL DETAILS
Title
 
First Name
 
Surname
 
Date of Birth
 
Tel No. (& area code)
 
Cellphone No.
 
Fax No.
 
E-mail Address
 
Residential Suburb
 
Area Postal Code
 
Marital Status
  Married
Single
Divorced
Widowed
Co-habiting / Partnered
How many years in total on all your vehicles have you had insurance?
 
Were you ever without vehicle
insurance for longer than 39 days?
  yes no
Have you suffered any losses /
submitted any claims in last 6 years?
  yes no
If yes, when and what type of claim?
 

VEHICLE DETAILS
Name & Surname of most regular driver
 
Date of Bith of Regular Driver
 
Regular Driver's I.D. Number
 
Date drivers license was issued
 
Vehicle year
 
Make & model
 
Value
 
Currently insured?
  yes no
If yes, how long?
 
Date of last claim
 
Any lapses longer than 39 days in the last 5 years?
  yes no
If yes, please indicate the date
 
Vehicle parking
  Overnight parking
Locked garage
Locked gates
Vehicle usage
 
Radio cover value
 
Vehicle security
  Immobiliser Gearlock
Anti-hijack Tracking device
Name of tracking company
 
Is the unit self-activating
  yes no
Is the unit standard call in system
  yes no
Comments
 

ADDITIONAL VEHICLE DETAILS
Name & Surname of most regular driver
 
Date of Bith of Regular Driver
 
Regular Driver's I.D. Number
 
Date drivers license was issued
 
Vehicle year
 
Make & model
 
Value
 
Currently insured?
  yes no
If yes, how long?
 
Date of last claim
 
Any lapses longer than 39 days in the last 5 years?
  yes no
If yes, please indicate the date
 
Vehicle parking
  Overnight parking
Locked garage
Locked gates
Vehicle usage
 
Radio cover value
 
Vehicle security
  Immobiliser Gearlock
Anti-hijack Tracking device
Name of tracking company
 
Is the unit self-activating
  yes no
Is the unit standard call in system
  yes no
Comments
 

 
 
 
       
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