SHORT TERM INSURANCE
Personal Lines Questionnaire
Privacy Statement
In order to provide you with a quote, Netsure Financial Consultants has to process your personal information. Netsure Financial Consultants will share your personal information with other insurers, industry bodies, credit agencies and service providers. This includes information about your insurance, claims and premium payments. Netsure Financial Consultants does this to provide insurance services, prevent fraud, assess claims and conduct surveys. Netsure Financial Consultants will treat your personal information with caution and has put reasonable security measures in place to protect it.
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PRE-QUOTE Questions:
In order to provide quotes please complete
Are you acting in your personal capacity? (and not a legal entity like a company or closed corporation?)
*
Yes
No (We only allow a natural person as the policyholder. Please contact us Directly)
Are you currently insolvent or under administration?
*
Yes (We cannot provide a quote if you are insolvent or under administration)
No
Do you give us permission to do an ITC check? (On your insurance risk score with any registered credit bureau to release any information that relates to your credit history and/or any other authorised financial services provider)
*
Yes
No (Please note that without ITC permission we cannot provide Quotes)
Has an insurer ever declined cover, cancelled or refused to renew any life or short-term insurance policy for you, anyone living with you, or anyone who will be covered under this policy?
*
Yes
No
If "Yes" please provide Cancelation Reason:
Not Applicable
Fraud or Misrepresentation
Non-Payment of Premiums
Unacceptable Claims Experience
Other
We will contact you to determine whether we can issue a quote
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Personal & Contact Details
PERSONAL & CONTACT DETAILS:
Please Complete in Full
Name
*
Mr.
Mrs.
Ms.
Miss
Prof.
Dr.
Rev.
Sir
Hon.
Adv.
Adm.
Brig.
Cpt.
Col
Com.
Gen
Lt.
Maj.
Title
First Names
Surname
Email
*
example@example.co.za
Phone Number
*
Physical Address
*
Street Address Line 1/Complex
Street Address Line 2
Suburb
City / Province
Postal Code
Identity Number
*
Required to Quote
Date of Birth
*
-
Day
-
Month
Year
Date
Marital Status
*
Married
Divorced
Separated
Single
Widowed
Life Partner
Select One
Spouse Name
Mr.
Mrs.
Ms.
Miss
Prof.
Dr.
Rev.
Sir
Hon.
Adv.
Adm.
Brig.
Cpt.
Col
Com.
Gen
Lt.
Maj.
Title
First Names
Surname
Spouse Identity Number
Employment Information
EMPLOYMENT INFORMATION:
Please Provide details of your Employment
Employment Status
*
Work for an Employer
Homemaker
Retired / Pensioner
Self-Employed
Student
Unemployed
Select One
Occupation
*
Manager, Professional or General Office Worker
Education, Social Services or Government Official
Manufacturing, Construction, Mining or Farming
Transport, Distribution or Logistics
Service or Sales Worker
Armed Forces
Select One
Occupation Description
Insurance & Claims History (Required)
EXISTING INSURANCE:
Please Provide details of your Insurance History
Are you currently Insured?
*
Yes
No
Current Insurer
Existing Insurance Policy Number
Current Premium
Number of years uninterrupted Insurance Cover
*
Never Been Insured
0 - 1 Year
1 - 2 Years
2 - 3 Years
3 - 4 Years
4 - 5 Years
5 - 6 Years
6 - 7 Years
7 - 8 Years
8 - 9 Years
9 - 10 Years
10 + Years
Select One
Kindly upload your current policy schedule - this will assist in quoting on your insurance needs
Browse Files
Click to upload
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CLAIMS HISTORY:
Please provide in full
Have you had any Claimsin the past 3 years?
*
Yes
No
If "Yes" Please provide as much detail as possible
Date
Description of Loss
Value of Loss
1
2
3
4
5
Kindly upload your Claims History Statement - This can be obtained from your current insurer
Browse Files
Click to upload
Cancel
of
Product Lines and Policy Information
PRODUCT LINES AND POLICY INFORMATION:
The more product lines you add the better the premium
What would you like to Insure? - Complete the Relevant Sections Below
*
Personal Motor - Car/Vehicle Insurance
Personal Contents - Household Contents
Personal All Risk - Portable Possessions
Personal Building - Home Insurance
Would you like to add Excess Waiver to your policy?:
Yes
No - Apply Standard Excess
Apply Minimum excesses
I would like my excess to be:
You can select a higher excess in order to reduce your premium or you can reduce your excess in exchange for a higher premium.
My preferred excess across all lines
Personal Motor
PERSONAL MOTOR
Car/Vehicle/Motorbike/Trailer & Caravan Insurance -Please Provide details in full
What type of cover do you require for your Vehicles?
Comprehensive
Limited
Third Party Only
Long Term Storage
Do you give us permission to check this Vehicle’s details and history on eNaTIS?
Yes
No
Vehicle Description(s)
Year
Make
Model
Colour
Reg No
M&M Code
Vehicle1
Vehicle2
Vehicle3
Vehicle4
Vehicle5
Vehicle Use
Personal Use
Business Use (20 or More Business trips a month)
Semi Business Use
(7-20 Business trips a month)
Commercial/ Agricultural Use
Taxi/Fare-Collecting Use
Vehicle1
Vehicle2
Vehicle3
Vehicle4
Vehicle5
Regular Driver Details
Full Name & Surname
ID Number
Drivers Licence Code
Drivers License Date of First Issue
Do You Require Car Hire?
Vehicle1
Yes
No
Vehicle2
Yes
No
Vehicle3
Yes
No
Vehicle4
Yes
No
Vehicle5
Yes
No
Are there any Extras on Vehicles?
Description and Value of Extras
Vehicle1
Vehicle2
Vehicle3
Vehicle4
Vehicle5
Vehicle Security
Alarm
Immobilizer
Tracking Device
Tracking Company
Other
Vehicle1
Yes
No
Yes
No
Yes
No
Vehicle2
Yes
No
Yes
No
Yes
No
Vehicle3
Yes
No
Yes
No
Yes
No
Vehicle4
Yes
No
Yes
No
Yes
No
Vehicle5
Yes
No
Yes
No
Yes
No
Vehicle Parking and Location & Security
Day Time Location (eg Locked Garage/Undercover/Access Controlled)
Day Time - Street Address
Night Time Location (eg Locked Garage/Undercover/Access Controlled)
Night Time - Street Address
Vehicle1
Vehicle2
Vehicle3
Vehicle4
Vehicle5
Finance Details - Credit Short Fall
Is The Vehicle Financed?
Creditor/Finance House
Amount Owed
Intrest Rate (%)
Term (Months)
Vehicle1
Yes
No
Vehicle2
Yes
No
Vehicle3
Yes
No
Vehicle4
Yes
No
Vehicle5
Yes
No
Personal Household Contents
PERSONAL HOUSEHOLD CONTENTS
Household Contents Insurance - Please Provide details in full
Property Type (Please select your type of home/dwelling)
House
Townhouse/Apartment (With Access Control)
Townhouse/Apartment (Without Access Control)
Flat (Ground Floor)
Flat (Above Ground Level))
Garden Cottage/Granny Flat
Storage Facility
Farm/Small Holding
What do you use your premises for?
Residential Only
Business Only (Cannot provide quote if building is for business/comercial purposes)
Residential and Business
If "Residential and Business" what home business are you running from premises?
What is your the buildings roof construction?
Tiles
Thatch
Concrete
Corrugated Iron
Slate
Fiber Cement
Asbestos
Wooden Shingles
Is the roof pitched or flat?
Flat
Pitched
What is your the buildings wall construction?
Bricks and Mortar
Stone
Concrete
Corrugated Iron
Precast Concrete
Fiber Cement
Asbestos
Wood
What is the sum insured of the home contents?
What is the value of jewellery and watches that are included in the above sum insured?
How many bedrooms at risk address?
1
2
3
4
5
6
7
8
9
10
How many geysers at risk address?
1
2
3
4
5
6
7
8
9
10
Is there thatch within 5m of your property?
Yes
No
What type of perimeter wall do you have?
Brick wall less than 1.8m
Brick wall less than 1.8m with Electric Fence
Brick wall more than 1.8m
Brick wall more than 1.8m with Electric Fence
Palisade wall less than 1.8m
Palisade wall less than 1.8m with Electric Fence
Palisade wall more than 1.8m
Palisade wall more than 1.8m with Electric Fence
Pre-Cast wall less than 1.8m
Pre-Cast wall less than 1.8m with Electric Fence
Pre-Cast wall more than 1.8m
Pre-Cast wall more than 1.8m with Electric Fence
Pre-Fabricated Wire Mech less than 1.8m
Pre-Fabricated Wire Mech more than 1.8m
Wood Fence less than 1.8m
Wood Fence less than 1.8m with Electric Fence
Wood Fence more than 1.8m
Wood Fence more than 1.8m with Electric Fence
Wire Fence
No Perimeter Fence/Wall
Please select what Security is applicable to your home?
Residing at Property
Burglar Bars (on all opening windows)
Burglar Bars (not on all opening windows)
Burglar Bars (on all fixed windows)
Security Gates (on all external doors)
Security Gates (not on all external doors)
Security Gates (on all Sliding doors)
Alarm (linked)
Alarm (not linked)
Access Control (signing in with guards)
Access Control (no guards)
24 Hour Guards on Patrol
Electric Fence (all round perimeter)
Neighbours All Round
Secure Estate
Armed Response
Dogs permanently at address
CCTV
Please select the type of adjoining land(s)
Residences
Offices
Retail
Schools
Farms
Agricultural Holdings
Unused Open Land
Informal Settlement
For how many days per year is the building left unoccupied?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
Are there any water bodies within 100m of your building?
Yes
No
Do you have surge protection Installed?
Yes
No
Do you require any optional cover
Accidental Damage (Cover for accidental damage to TVs and glass or mirrors forming part of a piece of furniture)
Garden and Outdoor (Covers loss or damage to generators, gardening equipment, power equipment, playground equipment and garden furniture kept in a location that is not attached to the building)
Personal Building
PERSONAL BUILDING
Building Insurance - Please Complete Contents Section for Building Details - Insured property (at risk address as stated in the schedule)
BUILDING REFERS TO:
The following, including: - Buildings (private residence and private outbuildings) - Fixtures and fittings belonging to the owner of the building while in or on the structures - Fixed recreational and ornamental structures - Paved and surfaced areas (including driveways) of brick, concrete, asphalt, synthetic grass or stone (not gravel) - Boundary and other walls, gate posts, gates (including all the machinery related to the gates), fences (other than hedges); - Tennis courts; - Swimming pools, spa baths, saunas and associated machinery and equipment, but not including movable swimming pools; - Satellite dishes; - Lightning conductors or masts; - Fixed electric generators; - Borehole machinery supplying water solely for domestic purposes; - Septic tanks.
What is the total specified buildings value at the risk address?
Do you have a swimming pool?
Yes
No
Do you have a generator?
Yes
No
Do you cook or Use Gas inside the Home?
Yes
No
Do you require any optional cover
Moisture Related Subsidence (Covers loss or damage caused by subsidence, landslip or ground heave that is related to the moisture content of the soil.)
Renewable Energy Equipment (Covers loss or damage to solar geysers, solar panels or wind turbines that are located outside or on the roof of the building)
Damage to Geysers (Covers loss or damage to electrical geysers, gas geysers, heat pumps and hot water tanks inside the building. Solar geysers are excluded)
Garden and Outdoor (Covers the cost of for re-landscaping the garden, removal of fallen trees and loss or damage to water pumps such as pool filters, boreholes, fish ponds and irrigation systems)
Accidental damage to Fixed Machinery?
Personal All Risks
PERSONAL ALL RISKS
Portable Possessions - Please note that items that leave the house like cell phones, laptops, tablets, jewellery, electronic items and any other personal effects should be specified under the All Risks Section in order to be covered.
What is the total unspecified possessions you would like to Insure?
These are items that you wear or carry around with you every day when leaving your home. For example, these could be clothing or personal belongings.
Should the Unspecified possessions include Electronic Equipment?
Yes
No
Specified Possessions
Description
Serial Number
Value
Item1
Item2
Item3
Item4
Item5
Item6
Submit Request for Quote
NETSURE FINANCIAL CONSULTANTS
Thank you for choosing Netsure Financial Consultants to assist with your insurance needs. At Netsure, we pride ourselves in offering our customers responsive, competent and excellent service.
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