Client Name:
ID Number:
Tel:
E-mail:
Fax:

Physical Address
Martial Status:
Household Section
Type of Dwelling:
Sum Insured:

Period at Address:
Roof Construction:
Wall Construction:
Dwelling Classification:
Burglar Alarm:
If yes is the alarm linked:
If yes with what company:
Burglar bars in
front of windows / louvers /
fanlights:
Occupied during working hours:
Unoccupied 45 days a year:
Buildings Section
Type of Dwelling:
Dwelling Classification:
Wall Construction:
Roof Construction:
Thatched Lapa:
Sum Insured:
Motor Vehicle Section
Year:
Make:
Model:
Retail Value:
Risk Address:
Security:
Registered Owner:
Regular Driver:
Date of Birth:
Car Hire:
Sound equipment to be covered:
Sound equipment value:
Overnight parking:
Sound equipment factory fitted:
Sound equipment cover required:
Vehicle Type:
All Risk Section
Unspecified items & values:
Specified items & values:


 

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