top of page
SHOWROOM
INTERNATIONAL SHOWROOM
ABOUT US
BLOG
Win with Vintage Motors
SERVICES
INSPECTIONS
WE SELL ON YOUR BEHALF
SHIPPING
AUCTION
INVESTMENT OPPORTUNITIES
CONTACT
INSURANCE QUOTATION
POLICY HOLDER DETAILS
Full Name
*
Email Address
*
Risk Address
*
Code
*
Phone
*
ID Number
*
Postal Code
*
INSURANCE HISTORY
Present Insurer
Has any insurer ever declinded to quote?
*
Yes
No
Has any insurer ever cancelled your insurance?
*
Yes
No
Has any insurer required an increase in premium or imposed special terms?
*
Yes
No
Has any insurer refused to renew your policy?
*
Yes
No
If yes, please supply full details:
Have you had any convictions/admission of guilt in the last 5 (five) years?
*
Yes
No
CLAIMS
PLEASE LIST ALL LOSSES OR ACCIDENTS DURING THE PAST THREE YEARS (WHETHER INSURED OR NOT)
Claim date
Type of motor claim
Amount
Claim date
Type of motor claim
Amount
Claim date
Type of motor claim
Amount
INSURED VEHICLES/MOTORCYCLES
(Use supplementary sheet for additional vehicles/motorcycles)
Make:
*
Year
*
Model:
*
Value:
*
Financed?
*
Yes
No
Is a tracking or alarm system fitted?
*
Yes
No
NAMED DRIVER/RIDER 1
Full Name
*
Licence details
*
Full
Learners
Date of Birth
*
Date obtained
*
NAMED DRIVER/RIDER 2
Full Name
Licence details
Full
Learners
Date of Birth
Date obtained
WHERE IS THE VEHICLE/MOTORCYCLE KEPT OVERNIGHT?
In a locked up garage
In a locked up yard
In a locked up parking garage
Parked in the street or road
Other
DETAILS OF INSURANCE COVER
Milage under 10 000km/year
Milage over 10 000km/year
CONSENT TO THE USE OF UNDERWRITING, CLAIMS AND OTHER RELEVANT INFORMATION
• Waive any right to privacy in respect of any insurance information provided by you or on your behalf regarding any insurance policy or claim made or lodged by you or on your behalf.
• Allow such information to be disclosed to any other insurance company or its agents.
• Allow us to verify the information provided by you against other legitimate sources or databases.
DECLARATION
All information provided is true and correct
Request a Quote
Thanks! We’ll send you a price quote shortly.
bottom of page
