PERSONAL INFO

Name:

Surname:

Email:

Contact number:

Cell number:

ID:

Gender:

Marital Status:

Male

Female

HOME CONTENTS & BUILDING:

Home Contents:

Value of Home Contents:

When did you move into this home?

Do you have an alarm in working order?

Claims information - last 3 years:

Buildings:

Current Building Value:

Wall Construction:

Roof Construction:

Additional information or cover required:

(Caravan / Trailor / Boats)

Yes

ALL RISKS:

Cellphone / Laptop:

Camera / Video camera:

Sporting Equipment:

Fire arms:

Clothing:

Other:

Description:

Value:

Value

VEHICLE DETAILS:

Full Description:

Year:

Regular Driver:

** incase Other

Name:

ID nr:

Drivers's Claim free years:

Driver's Date Obtained:

Type of Cover:

Overnight Parking: