MJD Risk Insurance Brokers

Title

First Name

Last Name

Occupation

ID Number

Age

Cell number

Email

Marital Status

Select valueMarried/Co-habitingSingleDivorced?seperatedWidowedOther

Risk Address

Street number and name Suburb City Province Postal code

Previously insured?

Select valueYesNo

Number of claims in the last 3 years?

Select value012More than 2

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Contents

Buildings

Motor

All Risks

Personal Liability

Personal Accident

Caravans/Trailer

Small craft

Click here for definitions of above cover

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Contents cover required?

Select valueYesNo

Cover

Select valueFullLimited (Theft exckuded)

Replacement value of contents

Contents Premium

NB Definition of average

Construction

Select valueStandardNon StandardThatch roof

Construction premium

Accidental damage

Select valueYesNo

Accidental damage premium

R  

Power Surge R25 000

Select valueYesNo

Power Surge Premium

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