GetQuotes – Q-Cover Insurance Brokers (PTY) Limited

Car & Household Insurance Quote

Please complete this form to the best of your ability.

Leave blank what is irrelevant.

Should you require cover for more than two vehicles or one household contents & building cover then please complete the form twice.

For caravans, campers, marine and pleasure crafts please contact us.

Full Name *

ID number *

Cell Phone Number *

Email Address

Gender *

Marital Status *

Occupation *

Full Residential Address *

Current Insurance Company

Current Premium

Has any insurance ever been declined or cancelled? *

ALL previous LOSSES (Value & Date of claim) *

VEHICLE ONE

Year

Make and Model (Full description)

Registered Owner

Regular Driver

Driver Date of Birth

Date of Drivers License First Issue

Drivers License Code

Do you require car hire?

What is the vehicle used for?

How long have you held uninterrupted comprehensive insurance?

Where will the vehicle be parked at night?

Where will the vehicle be parked during the day?

Are there any extras? (Total value)

Would you like excess protection?

Do you need cover for credit shortfall?

VEHICLE TWO

Year

Make and Model (Full description)

Registered Owner

Regular Driver

Driver Date of Birth

Date of Drivers License First Issue

Drivers License Code

Do you require car hire?

What is the vehicle used for?

How long have you held uninterrupted comprehensive insurance?

Where will the vehicle be parked at night?

Where will the vehicle be parked during the day?

Are there any extras? (Total value)

Would you like excess protection?

Do you need cover for credit shortfall?

HOUSEHOLD CONTENTS COVER

Value

Full Risk Address

Type of Residence

Burglar Bars

Security Gates

Electric Fence

Alarm

Security Estate

BUILDING COVER

Value

Construction Type

Is there any Thatch construction within 10m of the household? ie. lapa

ALL RISKS

Specified items such as Laptops, Cell Phones, Jewelry (Full Descriptions, Makes, Models & Value)

By clicking submit you confirm that all the above information is true and correct. Any false or misleading information will effect the accuracy of your quote and/or any claims at a later stage. Do you confirm? *