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Personal Information

First Name (required)

(required)
MarriedSingle

Physical Address


Buildings


StandardNon-StandardOccupiedUnoccupied


Household Contents


YesNo


StandardNon-StandardOccupiedUnoccupied


No SecurityLinked AlarmElectric FenceBurglar Bars on Open windowsSecurity Gates on Outside DoorsSecure Complex


Motor


PrivateBusiness


YesNo



MaleFemale


Sedan4x4LDVMinibus


ComprehensiveTP'F & TheftTheft Only




YesNo


YesNo


Less than 1 Year1-2 Years3-4 Years5 Years Plus

History of previous losses/claims. Please give full particulars in respect of all losses sustained by
you during the past three years, including claims which have been paid or not been paid.