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Quote Me - Elna Rudman Insurance Brokers - Wingate Park, Pretoria
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Information needed to quote on Personal Insurance
 
 
  General Information:
     
  Title:
  Gender:
  Initials:
  Surname:
  Date of Birth:
  Id nr:
  Tel Work:
  Fax Nr:
  Tel Home:
  Cell nr:
  E-mail:
  Residential Address:
  Postal Address:
     
  Other Insurance:
     
  Are you currently Insured?
  Insurance Company Name:
  Policy Nr:
  Period of Insurance:
  Claims in the last 5 years:
     
  Buildings:
     
  Roof Construction - Standard / Thatch / Other:
  Wall Construction - Standard / Other:
  Type of home - House / Flat / Other:
  Situation of Residence - Farm / Plot / Security / Other:
  Insure Value in Rand:
     
  Contents:
     
  Insured Value in Rand:
  Are all opening windows burglar barred?
  Are all fixed windows burglar barred?
  Are all access doors fitted with security gates?
  Does any outbuilding / Garage adjoining to the main residence have an inter leading door?
  Is the perimeter wall or steel fence 1.8m in height?
  Are there full time security guards on your property?
  Is there 24-hour access control to your property?
  Is you home protected with an alarm system?
  If yes, is the alarm SAIDSA Approved?
     
  All Risk
     
 
     
  Specified All Risks (Car Radio/Tape players/DC Players (not standard factory fitted), and cellular phones must be specified regardless of value, jewellery, electronic equipment taken out of home, sport equipment, ect.)
ItemValue in Rand
     
  Motor Vechicle / Motor Cycle Vehicle 1:
     
  Full Description (make and model):
  Year of Manufacture:
  Vehicle Retail Value:
  Registration Number:
  Engine Number
  VIN Number:
  Rebuild code 3?
  Insurance Type: (Comprehensive/Limited Comprehensive/Third party fire & theft/Third party):
  Usage: (Private/Business/Professional)
  Security Measures:
  VSS Immobiliser?
  VESA Level 3/4 Immobiliser?
  VESA Level 3/4 Gear Lock?
  Tracker Device?
  Where is vehicle parked at night?
  Any excisting damages?
  Registered Owner of vehicle
  ID number:
  Year of licence received:
  Regular Driver of vehicle:
  ID number:
  Year of licence received:
  Optional Car Hire?
 
     
  MOTOR VEHICLE / MOTOR CYCLE Vehicle 2
     
  Full Description (make and model):
  Year of Manufacture:
  Vehicle Retail Value:
  Registration Number:
  Engine Number
  VIN Number:
  Rebuild code 3?
  Insurance Type: (Comprehensive/Limited Comprehensive/Third party fire & theft/Third party):
  Usage: (Private/Business/Professional)
  Security Measures:
  VSS Immobiliser?
  VESA Level 3/4 Immobiliser?
  VESA Level 3/4 Gear Lock?
  Tracker Device?
  Where is vehicle parked at night?
  Any excisting damages?
  Registered Owner of vehicle
  ID number:
  Year of licence received:
  Regular Driver of vehicle:
  ID number:
  Year of licence received:
  Optional Car Hire?
     
  Trailer / Caravan
     
  Trailer / Caravan Retail Value:
  Registration Number:
  Make and Model:
  Year of Manufacture:
  VIN Number:
  Is the trailer / caravan kept undercover?
     
  Personal Computer:
     
  Make and Model:
  Serial Number:
  Value:
  Accessories:
  Accessories Value:
     
 


 
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