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Personal Details

* Title:

* Full Names:

* Surname:

ID Number:

* Date of Birth:

dd - mm - yyyy

* Gender:

* Language:

* Marital Status:

* Monthly Household Income:

* Occupation:

* Qualifications:

* Province:

* Nearest City/Town:

Suburb:

* Preferred Contact No.:

Home

Office

Cell

* Contact Number:

* Email Address:

Type of Insurance Required:

Car Home Life Business Medical Travel


Car Insurance
* Year:
* Value of Sound System:
* Years of claim free comprehensive insurance:
* Type of Cover:
* Overnight Parking:
* Vehicle Use:
* Vehicle Currently Insured?:
If Insured, Which Company?:
Interested in a Tracking Device?:	Yes


Home Insurance
* Type of Cover Required:
Value of Building:
Value of Home Contents:
* When did you move into this home?	mm - yyyy
* Have you suffered a burglary at this address?
* Do you have an alarm in working order?
* Home Currently Insured?:
If Insured, Which Company?:


Life Insurance
* Smoker?:
* Type of Cover Required:
* Amount to Insure:


Business Insurance
* Type of Business:
* Type of Cover Required:
* Currently Insured?:
If 'Yes' which company?:


Medical Aid
* Type of scheme you are interested in:
* Sector of employment:
Subsidy?:	Yes
% of subsidy:
Currently with a medical scheme?:	Yes
Which scheme?:
Premium per month:	R
Which option?
How many members of your family need to be covered?:
*Principal member	Spouse
Dependents (+21yrs)	Children
Is anyone to be covered on chronic medication?	Yes
Number of chronic users to be covered?
Cost of chronic medication per month	R
Specify chronic condition/s
Do you want cover for day-to-day expenses? (e.g. doctors & medicine)	Yes
Are you or your spouse older than 34 years of age?	Yes
* If 'Yes', have you belonged to a medical scheme(s) before 1 April 2001 to date?	No
* If 'No', have you previously belonged to a medical aid as an adult?	Yes
* If 'Yes', how many years in total?
* Name of scheme(s) :


Travel Insurance
* Travelling From:
* Travelling To:
* Required Cover:
Additional Cover:
* Number of Adults:
Number of Children:
* Policy Start Date:	dd - mm - yyyy
* Policy End Date:	dd - mm - yyyy
Beneficiary Details in Case of Death:
Beneficiary Name:
Beneficiary Surname
Beneficiary Tel:


Comments/Requests:
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Welcome to E-Insurance-Quotes

What's the definition of Insurance? To Facilitate reimbursement during a crisis situation, insurance means a promise of compensation for any potential future losses.

Let's re-phrase the above!

To facilitate you during a crisis situation. To compensate you for any potential future loss!

With this said and done can you afford not to have insurance?

At E-Insurance-Quotes we are not trying to sell you insurance, but rather take care you during a crisis and to compensate you for any potential future loss.

Insurance made easy.

So if you are looking for short term insurance whether it be car insurance, business insurance, travel insurance or long term insurance such as home insurance, life insurance or medical aid simply complete any one of our online insurance quote request forms to enable one of our dynamic brokers to contact you and facilitate your request.

Easy Insurance Quotes Quick Links

Short Term Insurance

   Motor Vehicle / Car Insurance
   Business / Income Insurance
   Travel / Holiday Insurance

Long Term Insurance

   Medical Aid /Hospital Plan
   Home / Household Insurance
   Retirement / Life Insurance

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