010 595 0222 | sales@flexisure.co.za (Sales) | claims@flexisure.co.za (Claims) | Flexi-Sure Brokers (Pty) Ltd | FSP No: 45005

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Home Insurance Quote
Personal Quotation
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1 Personal Details
2 Vehicle Insurance
3 Building Insurance
4 contents Insurance
5 Motorcycle /Trailer /Caravan
6 Watercraft Insurance
7 Submit Quote
Personal Details
Title
Full Initialsinitials
Surnamesurname
ID Number
Marital Status
OccupationOccupation
Tel Home
Tel Work
Cellphone
Emaila valid email
Address Details

Day-Time Risk Address:

Number
Street Nameyour full name
Complex Name
Suburb
Postal Code

Night-Time Risk Address:

Number
Street Nameyour full name
Complex Name
Suburb
Postal Code
Postal Address same as residencial address?
Postal Address
0 /
Has any insurance company ever cancelled or refused to renew your insurance?
Cancellation Reasonyour full name
Insurance Cancel Date
Insurer
Drivers License
Date Obtained
Code
Has Your License Ever Been Endorsed Because Of Wreckless Or Drunken Driving
Date of Endorsement
Reason
Do You Presently Have Comprehensive Vehicle Insurance?
How Longpick one!
Name of Insurer
Have You Had Any Vehicle Claims In The Last 7 Years?
How Many Claims
Vehicle Claim Date 1
Vehicle Claim Description 1
Claim Amount 1
Vehicle Claim Date 2
Vehicle Claim Description 2
Claim Amount 2
Vehicle Claim Date 3
Vehicle Claim Description 3
Claim Amount 3
Vehicle Claim Date 4
Vehicle Claim Description 4
Claim Amount 4
Vehicle Claim Date 5
Vehicle Claim Description 5
Claim Amount 5
Have You Had Any Losses For Which You Did Not Claim
Unclaimed Date
Damage Value
Unclaimed Description 5
Can we conduct an ITC Check?
Vehicle Details
Would you like a quote on Vehicle Insurance?
Registred Owner
Title
Full Initialsinitials
ID Number
Surnamesurname
Year Model
Vehicle Make
Colour Of The Vehicle
Has The Vehicles Engine Been Upgraded To Increase Performance?
What has been done?
0 /
What will vehicle be used for?
Who Will Drive The Vehicle Most Often And More Frequently Than Any One Else
Title
Full Initialsinitials
Surnamesurname
ID Number
Drivers License Code
Does The Regular Driver Presently Have Comprehensive Vehicle Insurance?
Have You Had Any Vehicle Claims In The Last 7 Years?
How Many Claims
Claim Date 1
Claim Description 1
Claimed Amount 1
Claim Date 2
Claim Description 2
Claimed Amount 2
Claim Date 3
Claim Description 3
Claimed Amount 3
Claim Date 4
Claim Description 4
Claimed Amount 4
Claim Date 5
Claim Description 5
Claimed Amount 5
Where Will The Vehicle Be Parked At Night?
Type Of Cover
Would You Like To Include A Courtesy Car
What Anti Theft Device Does The Vehicle Have
Would You Like To Include A Tracking Device
Does The Vehicle Have Any Extras?
List All Extras
0 /
Is the vehicle currently under finance?
Finance House
Engine Number
VIN Number
Reg Number
Do you require top-up/shortfall cover
Building Insurance
Would you like a quote on Building Insurance?
Type Of Residence
Floor Num
Are You The Owner Or Tenant
Type Of Roof Construction
Wall Construction
Date Moved In
How Many Geysers Do You Have?pick one!
Geysers Value
Building Replacement Value
Have You Had Any Previous Claims At This Address
Date of Building Claim
Description of Building Claim
Building Claim Amountyour full name
Use Of Dwelling
Would You Like To Include Subsidence & Landslip Cover
How Many Bedrooms
Do You Have A Lapa On The Premises?
Is The Lapa Attached To The House?
Home Contents Cover
Would you like a quote on Home Contents Insurance?
Type Of Residence
Floor Num
How Many Bedrooms
Access Controlled By Guards
Access Controlled By Electronic Access
Are You The Owner Or Tenant
Type Of Roof Construction
Wall Construction
Occupation Date
Contents Replacement Value
Have You Had Any Previous Claims At This Address
Date of Building Claim
Description of Building Claim
Building Claim Amountyour full name
Use Of Dwelling
Do You Have A Lapa On The Premises?
Is The Lapa Attached To The House?
Do You Have Burglar Bars On
Do You Have Security Gates On
Do You Have An Alarm
Name of Security Company
Is Your Home Occupied During Working Hours
By Who
Will You Home Be Unoccupied For More Than 45 Days Per Year
How Many Days
Is Your House Bordered By
Does You Home Have Electric Fence
Would You Like To Include Accidental Damage
How Much?
Do you want to include power surge cover
How Much?
Motorcycle/Caravan/Trailer Cover
Would you like a quote on Motorcycle/Caravan Insurance?
Choose Insurance
Retail Value
Top Up Cover Required
Registration No
Registration No
Year
Make
Model
Engine Number
VIN Number
Is vehicle registered as
Is the vehicle a full import
Has the vehicle been modified to alter the performance level
What has been done?
0 /
Type Of Cover
What will vehicle be used for?
What Anti Theft Device Does The Vehicle Have
List all Non-Standard Accessories - Description/Value (R)
0 /
Watercraft Insurance
Would you like a quote on Watercraft Insurance?
Name of Watercraft
Make and model
ACCESSORIES/SPECIAL EQUIPMENTmore details
0 /
Length of Watercraft
Type of pleasure-craft
Is the pleasure-craft self-built
Engine(s) Sum Insured
Hull Sum Insured
Engine make
Year
Number of Engines
Type of Engine
Hull Year of Manufacture
Serial/HIN Number
State the address where the pleasure-craft is normally kept
0 /
Is the pleasure-craft kept in a locked building overnight
What are the security arrangements at this address
0 /
Is the pleasure-craft still in mooring
What are the security arrangements at the mooring
0 /
Will the pleasure-craft be surf-launched
In what waters will the pleasure-craft be used
Have you had any accidents or losses in connection with any pleasure-craft you have sailed or owned
Accident Details
0 /
Skipper Experience (Years) & Qualifications
0 /
Is the pleasure-craft subject to a credit or similar agreement
Financial Institution
Send me a copy of this quote request
Emaila valid email
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Commercial Quotation
Click here to download the commercial quote form.
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010 595 0222 | sales@flexisure.co.za | Flexi-Sure Brokers (Pty) Ltd | FSP No: 45005

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