Executive Motor Cover: Quote Questionnaire

Please fill in all the required information. Anything with a * next to it is compulsory. If you hit submit button and the form does not send, look out for the red text - it will tell you what is wrong. Once you have fixed the errors, please submit it again.
Date
Please insert the date
MUA Branch *
Please select the MUA Branch
Broker
Broker *
Please fill in Broker.
Contact *
Please fill in Broker contact.
Telephone No. *
Please fill in Broker telephone no.
Fax No.
Please fill in your Brokers fax no.
Email *
Please fill in Brokers email.
Insured
Policy No. (if existing customer)
Please fill in the surname.
Surname *
Please fill in the surname.
Initials *
Please fill in the initials
Date of Birth *
Please fill in date of birth
ID/Passport No. *
Please fill in the identification number.
Occupation *
Please fill in Occupation
Mobile Number *
Please fill in the cell number
Email *
Please fill in the email
Driver
Surname *
Please fill in the drivers Surname.
Initials *
Please fill in the drivers initials.
ID No. *
Please fill in the drivers identification number.
Gender *
Please select drivers gender
Years with License *
date license was issued
Please select years with license
Driver Address: Day *
Please fill in drivers address during the day
Code *
Please fill in the address code
Driver Address: Night *
Please fill in drivers address during the night
Code *
Please fill in the address code
Driver CFG *
Please fill in the Driver's CFG
Driver Restrictions
Please fill in the driver restrictions
Vehicle Use
Vehicle Use *
Please select type of vehicle use.
Vehicle Parking
Usual Daytime parking Overnight Parking
*
Please select usual daytime parking for vehicle
*
Please select overnight parking
Vehicle
Year *
Please select the vehicles year
Make *
Please fill in the vehicles make
Model *
Please fill in the vehicle model
Vehicle Value
Accessories R
Please fill in the accessories value
Sound Equipment R
Please fill in the sound equipment value
Vehicle R
Please fill in the sound equipment value
Security
Existing Security *





Please select all which apply
Cover
Cover Type *





Please select your current cover type
Optional Benefits
Top Up *
Please select yes or no
Roadside Assist *
Please select yes or no
Car Hire
Please select no, standard or extended
Increase Windscreen cover *
Please select yes or no
Claims History
Please provide details of any losses in the last 3 years:
Date of Event
 
Description of Event
Invalid Input
Amount Claimed R
Invalid Input
Type of Claim




Invalid Input
Date of Event
Invalid Input
Description of Event
Invalid Input
Amount Claimed R
Invalid Input
Type of Claim




Invalid Input
Has any insurer ever refused, cancelled or declined to renew any policy held by you? *
Please select yes or no
If Yes please provide details
Invalid Input
Has the policyholder/proposer or main drivers been charged or convicted of any driving violations? *
Please select yes or no
If Yes please provide details
Invalid Input
Current Insurers Renewal Date Current NCB
Please fill in your current current insurers
Please provide your renewal date
Please fill in your current NCB
NOTICE:
You are reminded of the need to disclose all material facts that are likely to affect the acceptance or assessment of this insurance. If you are in any doubt as to what constitutes a material fact please consult your broker or MUA, as failure to disclose or misrepresentation of a relevant fact may invalidate your insurance or result in it not operating fully. You acknowledge that the sharing of insurance information (including credit information) for underwriting and claims purposes between insurers is in the public interest and hereby waive the right to privacy with regard to underwriting, credit or claims information.

GENERAL:
  • Vehicles must be registered in the Republic of South Africa
  • This quotation is inclusive of VAT, SASRIA but excludes broker fees.
  • This quotation is subject to the terms, exceptions, conditions, limits of indemnity and standard excesses of the company’s standard motor policy
  • No basic excess for insured persons over the age of 55, who have had a licence for more than 5 years, on any section of our motor policies (except Classic Motor)

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