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Car Insurance Home Insurance Life Insurance Business Insurance Medical Aid Travel Insurance
Personal Details
*Title:
*Full Names:
*Surname:
ID Number:
*Date of Birth: dd - mm - yyyy
*Gender:
*Language:
*Marital Status:
*Monthly Household Income:
*Occupation:
*Qualifications:
*Province:
*Nearest City/Town:
Suburb:
*Preferred Contact No.:
*Contact Number:
*Email Address:
Type of Insurance Required:
Car Home Life Business Medical Travel
Car Insurance
*Year:
*Value of Sound System:
*Years of claim free comprehensive insurance:
*Type of Cover:
*Overnight Parking:
*Vehicle Use:
*Vehicle Currently Insured?:
If Insured, Which Company?:
Home Insurance
*Type of Cover Required:
Value of Building:
Value of Home Contents:
*When did you move into this home? mm - yyyy
*Have you suffered a burglary at this address?
*Do you have an alarm in working order?
*Home Currently Insured?:
If Insured, Which Company?:
Life Insurance
*Smoker?:
*Type of Cover Required:
*Amount to Insure:
Business Insurance
*Type of Business:
*Type of Cover Required:
*Currently Insured?:
If 'Yes' which company?:
Medical Aid
*Type of scheme you are interested in:
*Sector of employment:
Subsidy?: Yes
% of subsidy:
Currently with a medical scheme?: Yes
Which scheme?:
Premium per month: R
Which option?
How many members of your family need to be covered?:
*Principal member  Spouse 
Dependents (+21yrs)  Children
Is anyone to be covered on chronic medication? Yes
Number of chronic users to be covered?
Cost of chronic medication per month R
Specify chronic condition/s
Do you want cover for day-to-day expenses? (e.g. doctors & medicine) Yes
Are you or your spouse older than 34 years of age? Yes
*If 'Yes', have you belonged to a medical scheme(s) before 1 April 2001 to date? No
*If 'No', have you previously belonged to a medical aid as an adult? Yes
*If 'Yes', how many years in total?
*Name of scheme(s) :
Travel Insurance
*Travelling From:
*Travelling To:
*Required Cover:
Additional Cover:
*Number of Adults:
Number of Children:
*Policy Start Date: dd - mm - yyyy
*Policy End Date: dd - mm - yyyy
Beneficiary Details in Case of Death:
Beneficiary Name:
Beneficiary Surname
Beneficiary Tel:
Comments/Requests:
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