Tel: 011 279-1770
Fax: 011 760-2299
Email: loraine@economybrokers.co.za
Website: www.economybrokers.co.za
Postal Address: P.O. Box 6693, Westgate, 1734

Please complete following sections and click "Submit"

Personal Information
Title: Name: Surname:
Date of Birth: Cell No: Home no:
Work no: Email:
Residential Address:
 Postal Address:
Postal code of Residence: Occupation:
Gender: Ethnic Group:


Motor Cover
Cover Type: Alarm Installed? Yes No Anti-Hijack? Yes No
Imobilisor Installed? Yes No Gear Lock Installed? Yes No
Vehicle Make: Model: Year:
Vehicle Colour: Sum to Insure: R NCB:
Is a Radio Installed? Yes No Radio's Value: R
Vehicle's Use: Where is vehicle Parked at night?


Household Cover
Sum to Insure: R How long have you lived here:
Dwelling Type: Roof Type: Wall Type:
NCB: Is your house situated on a plot or smallholding? Yes No
Is your house nearby an open veld or park? Yes No
Are all opening windows protected by burglar bars? Yes No
Is your home fitted with a burglar alarm system linked to an armed reaction unit? Yes No
Are there glass panels in or directly next to the doors leading to the outside? Yes No
Are these glass panels protected by security gates? Yes No
Are these security gates fitted to all doors leading to the outside? Yes No
Are there sliding doors leading outside? Yes No
Are these sliding doors protected with security gates? Yes No
Is your house occupied during normal working hours? Yes No
If you live in a flat, is it on the ground floor? Yes No
Does your flat have burglar proofing at the passage wayside? Yes No


All Risk Cover
Unspecified:
Discription: Amount: R
Specified:
Item 1: Amount: R
Item 2: Amount: R
Item 3: Amount: R