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Section 1: General client details


Name
Surname
Marital status
Gender
Date of birth
Physical address




Number of years at address
Is this house on a smallholding

Section 2: Financial information

Section 3: Household insurance


Previous insurance	Policy number
	Number of years insured
	Insurer
	Premium payalbe	R
	How many cliams
	Value of claims	R

Residence	In a resedential area
	Value of contents	R
	Burglaries
	Building Sum insured	R
	Linked alarm (Armed response)
	Burglar bars at all windows that open
	Thatch
	Electric fencing
	Complex with controlled access
	24-hour security guards
	Claims free years

Use of building	Business operated from home
	Insured amount(Unspecified)	R

All risks specified e.g. jewellery, electronic equipment, computers, cell phones, etc	Item 1	Value R
	Item 2	Value R
	Item 3	Value R
	Item 4	Value R
	Item 5	Value R

Section 4: Motor vehicle insurance

	1^st Vehicle	2^nd Vehicle
Make
Year
Colour
Retail value including extras	R	R
Private or business use (state which - not both)
Comprehensive or 3^rd party cover
Number of claim free years at current insurer
Vesa level 3 or 4 immobiliser / tracking/ gear-lock (specify)
Overnight parking (garage / behind locked gates / open)
Daytime suburb parking
Registered owner
Date of drivers licence received
Vehicle Financed? Top-up Req?
Radio cover value	R	R

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