Please enable JavaScript in your browser to complete this form.Personal Information. Car Insurance - Step 1 of 4Name: *FirstLastID number:Marital statusSingleCo-habitatingMarriedDivorcedSeparatedWidowedEmail: *Cell number:AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeNextYear202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993MakeABARTHALFA ROMEOAUDIBMWCHERYCITROENDATSUNFAWFIATFORDFUSOGWMHAVALHONDAHYUNDAIISUZUJAGUARJEEPKIALAND ROVERLEXUSMAHINDRAMAZDAMERCEDES BENZMINIMITSUBISHINISSANOPELPEUGEOTPORSCHERENAULTSMARTSUBARUSUZUKITATATOYOTAUD TRUCKSVOLKSWAGENVOLVOModelDescriptionColourWhiteBlackGreySilverRedBlueBrownGreenBeigeOrangeGoldYellowPurpleMetalic Paint?YesNoDo you have a Motorcycle or more than one car to insure?YesNoWhat type of cover do you require?ComprehensiveThird Party Fire & TheftThird Party OnlyWhere is your car parked overnight?Access Controlled AreaBasement - Electronic AccessBasement - No Electronic AccessLocked GarageOn Pavement / in StreetOpen Parking LotYard - No Locked GatesYard - With Locked GatesNextWho is the main driver?MeSomeone elseWhat type of licence do you haveRSA Driver LicenceRSA Learner LicenceInternational Driver LicenceWhen was your License first issued?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driver license code?AA1BC1CEBEC1ECHow long have you had uninterrupted comprehensive car insurance for? 0 Years1 Years2 Years3 Years4 Years5 Years to 10 years10 Years plusHow many years has it been since your last car accident or theft claim?Never had a claimWithin the last 12 months1 to 2 Years2 to 3 Years3 to 4 Years5 to 6 Years6 to 10 Years10 Years plusNextHow much building cover would you like? (eg.R5000)Do you want to include geyser cover?YesNoValue of home contents (eg. R5000)When did you move in?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have burglar bars on all windows?YesNoDo you have security gates at all open doors?YesNoHave you had a break-in at this address?YesNoIs your home occupied during working hours?YesNoDo you have an alarm in working order?YesNoDo you have neighbours on all border?YesNoDo you have a parameter wall 1.8m or higher?YesNoDoes your property have electric fence?YesNoDo you live in an Access Controlled Estate?YesNoPreviousSubmit
