Insurance Request Form

Please Fill in ALL FIELDS

SECTION A

Title
Name: In Full
Occupation
Male	Female
Physical Address
Town/City
Province
Postal Code
Age
Telephone
Mobile Phone
Email
I.D No.

SECTION B Householders Questionaire

HOUSE CONTENTS:SUM INSURED	R
HOUSEOWNER:SUM INSURED	R
TYPE - STANDARD THATCH
UNOCCUPIED + 30DAYS YES / NO	/
OPPOS./ GROUND YES / NO	/
PREVIOUS / CURRENT INSURERS NAME
POLICY NO.
BURGLAR BARS	YES NO
SECURITY GATES	YES NO
ARMED RESPONSE	YES NO
TOWNHSE.LTD ACCESS	YES NO
FLAT ABOVE GROUND	YES NO
ELECTRIC FENCES	YES NO
CONSTANT OCCUP:	YES NO
PENS.OVER 55 N / WORK	YES NO
WHEN DID YOU REQUIRE YOUR DRIVER'S LICENSE?
NB: NOTE ANY CLAIMS FOR THE LAST 3YEARS

SECTION C : All Risks
UNSPECIFIED	R
SPECIFIED	R
CYCLES	R
CONTACT LENSES	R
CAR RADIO	R

SECTION D MOTOR VEHICLE

MAKE
MODEL
VALUE
YEAR
NCB	1 2 3 4 5 6	1 2 3 4 5 6	1 2 3 4 5 6
COVER ( COMP/TPFT)
USE	PRIVATE / BUSINESS	PRIVATE / BUSINESS	PRIVATE / BUSINESS
CAR HIRE	YES NO	YES NO	YES NO
SECURITY	G/LOCK, N/STAR,IMMOB,ALARM	G/LOCK, N/STAR,IMMOB,ALARM	G/LOCK, N/STAR,IMMOB,ALARM
DRIVER	Male Female	Male Female	Male Female