| Title: * |
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Initials: * |
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| Surname: * |
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ID Number: * |
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| Date Of Birth: * |
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Marital Status: * |
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| Occupation: * |
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Gender: * |
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| Language: * |
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Cell Number: * |
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| Tel Home: * |
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Tel Work: * |
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| Email Address: * |
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| ADDRESS INFORMATION |
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| Physical Address : |
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| Code : |
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| Please mark on the items Genesure must quote on
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| HOME OWNERS |
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| HOUSE CONTENT |
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| HOLIDAY HOMES & CONTENT |
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| SPECIFIED ALL RISKS (CELLPHONES, LAPTOPS, JEWELLRY e.g.) |
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| VEHICLES |
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| MOTORCYCLES |
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| SPECIAL VEHICLES (GOLF CARS, QUAD BIKES, e.g.) |
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| CARAVANS / TRAILERS / SMALL CRAFTS |
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| GENERAL INFORMATION |
| 1.1 Are you currently insured and for how long? |
| Name Of Insurer : |
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Policy Number: |
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| Period of Insurance (mm/yy to mm/yy) : |
| From : |
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To : |
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| 1.2 Have you suffered any loss in the past 5 years? If so, provide details of each such loss(es) below, including
uninsured or unclaimed losses.
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| PREVIUOS CLAIMS HISTORY |
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Type of loss (fire, motor, all risks, burglary, accident, etc.) |
Date of Loss |
Amount claimed and Insurer |
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| 2. |
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| 3. |
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