| First Name | |
| Last Name | |
| ID NUMBER OR PASSPORT | |
| Occupation | |
| Gender | Select ValueMaleFemale |
| Have you ever been declined insurance? | Select ValueYesNo |
| If Yes please provide details | |
| Your Previous Claims | Select ValueYESNO |
| Property Type | Select ValueDetached House / CottageSemi Detached / CottageFlat ( above first floor )Flat ( ground / first floor) |
| Where is the property situated? | Select ValueEnclosed access control area eg. automatic entry gatesHigh Security EstateResidential Area ( Not Enclosed ) |
| Roof Type | Select ValueTileThatchSlateMetalConcreteOther |
| Wall Type | Select ValueBrick/Stone or ConcreteAsbestos or Timber CladMetal frame and fiberglassTimber / part Timber Framed MetalPrefabricated Sandwich Panels |
| How Many Geysers do you have? | Select Value123 |
| Do you have a solar Geyser? | Select ValueYESNO |
| Are all accessible windows protected by Burglar Ba | Select ValueYESNO |
| Are all accessible doors protected with Security G | Select ValueYESNO |
| Is the property fully walled and or Fenced | Select ValueYESNO |
| Is the perimeter wall and or Fence fitted with E | Select ValueYESNO |
| Are there full time security Guards on the propert | Select ValueYESNO |
| Does your property have an alarm system installed | Select ValueYESNO |
| Is there 24 hour access control to the property | Select ValueYESNO |
| Do you require a quote for your Household Contents | Select ValueYESNO |
| Do you require a quote for your Motor Vehicle or s | Select ValueYESNO |
| Gender of Driver – Vehicle 2 | Select Value |
| Do you require All Risks Cover | Select ValueYESNO |
| Do you require Trailer Insurance | Select ValueYESNO |
| Do you require Caravan Insurance? | Select ValueYESNO |
| Do you Require Motorcycle Insurance | Select ValueYESNO |
| Do you require Watercraft Insurance | Select ValueYESNO |
| Provide Full Description Of Vessel | |
| Consent | |
| Postal Address | |
| Address Line 2 | |
| Province |
031 765 5075
myles@smbinsurance.co.za
Recent Comments