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Combined Insurance
The important stuff we need to get you started!
Don’t fill this out if you’re human:
1
Personal Info
Name
Email
Tel. No.
Marital Status
Select
Single
Married
Employment Status
Select
Unemployed
Employed
2
Household Details
Value ($)
House Description
Select
Town House
Apartment
House
Situated Area
Select
Residential
Other
Holiday Home
Select
Yes
No
Type of Cover
Select
Household & Home
Household
Home
3
House Security Info
Is home near open fields?
Select
Yes
No
Home in secure complex?
Select
Yes
No
Security gates on external doors?
Select
Yes
No
Is house fitted with an alarm?
Select
Yes
No
Non-standard construction?
Select
Yes
No
4
Car Details
Make
Year
Model
Value ($)
5
Driver Info
Name
D.O.B.
Driver License #
License Issue Date (eg. 2020/11/01)
Custom or Rebuilt Vehicle
Select
Yes
No
Driver is:
Select
Policy Holder
Spouse
6
Car Insurance Info
Tracking Device Installed
Immobiliser Fitted
Insurance Type
Select
Comprehensive
3rd Party
Vehicle Use
Select
Business
Private
Have You Claimed Before?
Select
Yes
No
Submit Info
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