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Request Form

SOUTHNATIONAL ALL RISK

SHORT TERM INSURANCE BROKERS The Service is on us….because we understand the power of a Promise.

SECTION A

Title:
Full name:
Occupation:
Gender:
Male Female
Physical Address:
Town / City:
Province:
Postal Code:
Age:
Telephone:
Mobile Phone:
Email:
ID NO:

SECTION B: Householders Questionaire

House Contents: Sum Insured
R
House Owner: Sum Insured
R
Type:
Standard Thatch
Occupied + 30 Days:
Yes No
Oppos./Ground:
Yes No
Previous / Current Insurers Name:
Policy Number:
Burglar Bars:
Yes No
Security Gates:
Yes No
Armed Response:
Yes No
Townhouse Limited Access:
Yes No
Flat Above Ground:
Yes No
Electric Fences:
Yes No
Constantly Occupied:
Yes No
Pensioners Over 55 N / Work:
Yes No
What year did you acquire your drivers licence?:
NB: Note any claims for the last 3 years

SECTION C: All Risks

Unspecified:
R
Specified:
R
Cycles:
R
Contact Lenses:
R
Car Radio:
R

SECTION D: Motor Vehicle

Make:
Model:
Value:
Year:
NCB:
1 2 3 4 5 6
Cover (Comp/TPFT):
Use:
Private Business
Security:
G/LOCK, N/STAR, IMMOB, ALARM
Driver:
Male Female
Verification code:
verification image, type it in the box