Quote Request for Motor Vehicle Insurance Step 1 of 3 33% General InformationReferred ByName(Required) First Last Date of Birth(Required) YYYY dash MM dash DD Phone(Required)Email(Required) 1. How many years have you been driving? (Issue date of DP)(Required)20252024202320222021202020192018201720162015More than 10 years2. Who is your Current/Previous Insurer?(Required)3. Are you seeking Full Comprehensive or Third Party Insurance?(Required) Comprehensive Third Party, Fire & Theft Third Party Only Please input the details of any other driver to be named on the policy(Required)None123Select the number of additional drivers on the policy above.Date of Birth of additional driver 1(Required) MM slash DD slash YYYY 4. How many years has this driver been driving? (Issue date of DP)(Required)20252024202320222021202020192018201720162015More than 10 yearsDate of Birth of additional driver 2(Required) MM slash DD slash YYYY 5. How many years has this driver been driving? (Issue date of DP)(Required)20252024202320222021202020192018201720162015More than 10 yearsDate of Birth of additional driver 3(Required) MM slash DD slash YYYY 6. How many years has this driver been driving? (Issue date of DP)(Required)20252024202320222021202020192018201720162015More than 10 years Vehicle InformationMake of vehicle(Required)Model of vehicle(Required)Vehicle body type(Required) Van Sedan Hatchback Station Wagon S.U.V. Pick Up Manufacturer Year(Required)202520242023202220212020201920182017201620152014201320122011More than 15 years agoPlease state the engine size in cubic centimetres (CCs) for personal vehicles or the engine power in Horse Power (HP) for commercial vehicles(Required)Current Condition of Vehicle(Required)Brand New (import)Brand New (local showroom)Foreign UsedLocal Used7. Do you require windscreen cover?(Required) Yes No 8. What limit of windscreen cover do you prefer?(Required)$1,000 - $3,000$3,000 - $5,000$5,000 - $8,000$8,000 - $10,000Over $10,000Please give current estimated value of the vehicle (for Third Party coverage please put 0)(Required) Claim History9. Have you made any claims in the past 5 years?(Required) Yes No 10. What year your most recent claim?(Required)202520242023202220212020Over 5 years ago11. Can you give any further details?(Required)
