TELEMARKETING QUOTE REQUEST
DATE
AGENT NAME
PARTICULARS OF PROPOSER
TITLE
FIRST NAMES
SURNAME
IDENTITY
NUMBER
MARITAL
STATUS
OCCUPATION
CELL NUMBER
WORK NUMBER
HOME NUMBER
EMAIL ADDRESS
RISK ADDRESS
(RESIDENCE 1)
CODE:
Do you have current YES NO Duration Premium
insurance?
Where you previously YES NO Duration
insured?
Have you obtained any YES NO Company Premium
quotes?
How long have you had uninterrupted comprehensive insurance
DECLARATION BY CLIENT
1. Has any Insurer/Underwriter ever cancelled/declined/refused to renew or imposed YES NO
special terms or conditions on any policy held by you?
If YES, provide details:
2. Have you or any other person to be insured by this policy ever been insolvent or YES NO
under judicial management or had any civil judgements taken against you?
If YES, provide details:
3. Have you ever had any criminal convictions or do you have any criminal cases pending YES NO
against you?
If YES, provide details:
4. Do you give CLIENTSURE permission to do a financial and insurance background check YES NO
against you?
5. Are you aware of any fact about you or the risk to be proposed herein that could YES NO
PDF created with pdfFactory Pro trial version www.pdffactory.com.au
influence any insurer’s decision to insure the property?
If YES, provide details:
COVER SELECTED (Please tick relevant boxes)
BUILDING HOUSEHOLD GOODS (Contents) ALL RISKS
PERSONAL LIABILITY MOTOR CARAVAN /TRAILER
PERSONAL ACCIDENT PLEASURE CRAFT MOTOCYCLE
BUILDING AND/OR CONTENTS SECTION INFORMATION
Any claims or losses in the past 7 years, whether insured or not? YES NO
If YES please provide details as
follows
DATE DESCRCIPTION AMOUNT
HOW MANY RESIDENCE ARE WE INSURING?
PHYSICAL ADDRESS OF OTHER DWELLINGS
RISK ADDRESS
(RESIDENCE 1)
CODE:
CONSTRUCTION
ROOF CONSTRUCTION
WALL CONSTRUCTION
ANY THATCH YES NO
If YES is there an SABS approved lightning YES NO
conductor?
TYPE OF RESIDENCE (Please tick relevant box)
Main residence Cottage Holiday Home Other
House Town House Flat (incl Level) Complex Retirement
Village
Other (Please specify)
SECURITY MEASURES
PDF created with pdfFactory Pro trial version www.pdffactory.com.au
Do you have burglar bars in front of all open windows, including YES NO
louvres?
Security gates in front of open doors as well as sliding doors? YES NO
An Alarm System YES NO
Is the alarm linked to a 24 hr control room, with armed response? YES NO
Electric Access Control 24hr guards Perimeter Wall
Fence 1.8 meters high
Other (please specify)
Is any section of the building used for business purposes? YES NO
If YES, provide details of business:
Is the premises occupied during the day? YES NO
If YES, by whom (relationship):
Will the residence be left unoccupied for more than 60 consecutive days? YES NO
Is the residence in an established build up area? YES NO
Is any section of the building used for business purposes? YES NO
Is the residence near a park/sports field / golf course/vacant stand? YES NO
If YES, provide details:
Is the residence near a school/shopping centre? YES NO
If YES, provide details:
Is the residence within 5 kilometres of an informal settlement? YES NO
Are there any new buildings being built in your immediate neighbourhood? YES NO
Do you employ garden service? YES NO
Is the residence within 5 kilometres of an informal settlement? YES NO
LIMITS OF INDEMNITY
BUILDINGS SUM INSURED CONTENTS SUM INSURED
Main home R Contents inc jewellery R
Outbuilding R Outdoor & Garden Furniture R
Subsidence & Landslip R Business Contents R
ANY LOSSES/CLAIMS IN THE PAST 7 YEARS OF WHETHER INSURED OR NOT?
DATE OF LOSS DETAILS OF LOSS NAME OF INSURER COST (Approx)
R
R
R
R
R
R
R
PDF created with pdfFactory Pro trial version www.pdffactory.com.au
ALL RISKS
Do you want to insure any clothing and personal effects under the unspecified section?
UNSPECIFIED ITEMS VALUE
Clothing and personal effects R
Is there any item that you would more specifically wan to insure? Eg :cellphone, laptop etc
SPECIFIED ITEM VALUE
R
R
R
R
MOTOR SECTION
DETAILS VEHICLE 1 VEHICLE 2
Make
Model
Year of manufacture
MM Code
Transmission Automatic /Manual
Retail Value R R
Extras
Description Value
R
R
R
R
R
Colour
Registered Owner
Identity number of registered owner
Is the vehicle modified/turbo charged
Has the vehicle been registered as a CODE 3 (rebuilt)
SECURITY
Factory Fitted Alarm
Vesa Approved Immobiliser (level 3or4)
Gearlock
Data Dot
Tracker (which company)
CLASS OF USE
Private use
Private incl to and from work
Professional/ Business
TYPE OF COVER
Third Party Only
Third party fire & theft
Comprehensive Cover
PDF created with pdfFactory Pro trial version www.pdffactory.com.au
EXCESS WAIVER- Explanation: This will reduce your basic excess
to NIL for the most regular driver
Excess waiver buyback
Regular Driver: Who will drive the vehicle most often?
Insured
Spouse
Other, if yes please include details below
Relation to insured
Title
Surname
Name
Identity No
Occupation
Licence codes: A A1 B C C1 EB
EC EC1 Learners
Licence code
Date of licence issue
Any restrictions imposed on licence?
If yes provide details of restriction
Has your licence been suspended?
If yes provide details of suspension
Do you want a named driver policy? This would only insure
people who are named on the policy and the premium would be
cheaper.
NO CLAIM BONUS (NCB) / CLAIM FREE GROUP (CFG) –
Explanation: For every year that you do not claim, you get a NCB/
CFG, the higher your discount and in turn reducing you premium.
If yes provide details of restriction
Do you require car hire?
DAYTIME PARKING
Day Address (Suburb)
Security at address (please select below)
Locked Garage
Secure Car port
Security complex
On Road
Behind secure gates
Other (please specify)
NIGHT TIME PARKING
Night Address (Suburb)
Security at address (please select below)
Locked Garage
Secure Car port
Security complex
On Road
Behind secure gates
Other (please specify)
ANY LOSSES/CLAIMS IN THE PAST 7 YEARS OF REGULAR DRIVER
WHETHER INSURED OR NOT?
DATE OF LOSS DETAILS OF NAME OF COST
PDF created with pdfFactory Pro trial version www.pdffactory.com.au
LOSS INSURER (Approx)
R
R
R
R
R
R
R
PDF created with pdfFactory Pro trial version www.pdffactory.com.au
