You can fax your current insurance schedule (papers stating items insured for how much) to 086 502 2791 along with your contact details to instantly provide us with the details we need to quote you. Alternatively, please fill in the form below. CAR AND/OR HOUSEHOLD INSURANCE QUOTATION REQUEST FORM
Please complete the relevant sections below. * Denotes a required field. Click here to return to the main page.
Your Name: *
ID Number: *
Occupation: *
Marital Status: *
Residential Suburb: *
Postal Code: *
Contact number: *
E-mail address: *
INSURANCE DETAILS
Currently Insured? *	Yes No
Previous/Current Insurance Company:
CLAIMS HISTORY (Claims from your own insurance)
Motor Claims ever? *	Yes No	How many claims :	Amounts:
Houshold contents claims ever? *	Yes No	How many claims:	Amounts:
Building claims ever? *	Yes No	How many claims:	Amounts:
All Risks claims ever? *	Yes No	How many claims:	Amounts:
HOUSEHOLD CONTENTS
Residential Suburb: (if different from above)
Postal Code:(if different from above)
How long have you been at your current address?	years
Insured amount:	R
Type of residence:	House Flat Townhouse
Security Measures?:	Linked Alarm Burglar Bars Safety Gates
Wall Construction:	Standard Non-Standard Other
Roof Construction:	Standard Thatched Lightning conducter? Treated? Other
Claim free group / No Claim bonus (if known) (This is the number of years stated on your current insurance schedule. If you are newly insured select 'New', or if you are unsure, select 'Unsure'.)	years New Unsure
How long have you been insured for this section under your own insurance policy, or as a co-policy holder?	full years
BUILDINGS
Residential Suburb: (if different from above)
Postal Code: (if different from above)
Insured Amount:
Wall Construction:	Standard Non-Standard Other
Roof Construction:	Standard Thatched Lightning conducter? Treated? Other
ALL RISKS
Unpecified (cover for general everyday items that you carry with you, excluding cellphones & jewellry)	R
Jewellry	R
Sunglasses / Spectacles & Contact Lenses	R
Sporting Equipment	R
Cell Phones	R
Photographic Equipment	R
Other Specified (Please specify what)	R What?
Car Radios	R
Computer Equipment	R
VEHICLE 1
Type of Insured Vehicle:	Motor Vehicle Motor Cycle Caravan Trailer
When was driver's license obtained (of regular driver)
ID number of regular driver? ( If different from ID of policyholder )
Is the insured the Registered owner?:	Yes No
Year:
Make:
Model:
Security:	Alarm Immobiliser Gearlock Tracking
Where is vehicle parked at night?:	Locked Garage Street Behind Locked Gates
Cover:	Comprehensive 3'rd Party Only 3'rd Party & Fire & Theft
Use:	Private Business
Insured amount:	R
Claim free group / No Claim bonus (if known) (This is the number of years stated on your current insurance schedule. If you are newly insured select 'New', or if you are unsure, select 'Unsure'.)	years New Unsure
How long has the driver been insured for this section under his/her own insurance policy, or as a co-policy holder or a spouse of a policy holder?	full years
Regular Driver:	Insured Spouse Child Other
Age of regular driver:	years
Is the vehicle Financed?	Yes No
If so, by whom?
VEHICLE 2
Type of Insured Vehicle:	Motor Vehicle Motor Cycle Caravan Trailer
When was driver's license obtained (of regular driver)
ID number of regular driver? ( If different from ID of policyholder )
Is the insured the Registered owner?:	Yes No
Year:
Make:
Model:
Security:	Alarm Immobiliser Gearlock Tracking
Where is vehicle parked at night?:	Locked Garage Street Behind Locked Gates
Cover:	Comprehensive 3'rd Party Only 3'rd Party & Fire & Theft
Use:	Private Business
Insured amount:	R
Claim free group / No Claim bonus (if known) (This is the number of years stated on your current insurance schedule. If you are newly insured select 'New', or if you are unsure, select 'Unsure'.)	years New Unsure
How long has the driver been insured for this section under his/her own insurance policy, or as a co-policy holder or a spouse of a policy holder?	full years
Regular Driver:	Insured Spouse Child Other
Age of regular driver:	years
Is the vehicle Financed?	Yes No
If so, by whom?
ADDITIONAL OPTIONS
Excess Reducer? * ( Some policies have an option to reduce the excess payable in the event of a claim - this does increase the monthly premium slightly )	Yes No
Courtesy Vehicle in case of vehicle repairs / loss? *	Yes No
Top Up Cover? * ( Settle all oustanding finance debt over and above amount paid out when the car is stolen or written off )	Yes No
Any other notes or additional items (e.g. water craft, extended liability)?
Tel: (021) 872 5400 / 5600 | Fax: (086) 524 9573 E-mail: pieter@earthcover.co.za | Internet: www.earthcover.co.za Licensed Financial Services Provider FSB License number : 27491 © 2006 Earthcover Financial Services free website counter