Insurance Quote Form - OneNet Health and Insure

Do you require cover for your Building?*
- Yes
- No
Sum Insured*
Please enter a number greater than or equal to 200000.
Do you require cover for your Home Contents?*
- Yes
- No
Sum Insured*
Please enter a number greater than or equal to 150000.
Do you have Thatch?*
- Yes
- No
Either Roof or Lapa
How Many Geysers - Select Applicable*
- 1 - One
- 2 - Two
- 3 - Three
- My Geyser is Solar
Security Questions - Select Applicable*
- Burglar Bars & Security Gates
- Alarm Linked
- Electric Fence
- Living in a Secure Complex
Do you require cover for All Risks?*
- Yes
- No
Items out of the house. Eg: Cell Phone, Laptop, Jewellery
List of All Risks
Description Value
Do you require cover for Motor?*
- Yes
- No

Vehicle 1*
Year Full Make & Model Value Colour
Non-Standard Extra's
Description Value

Eg. Towbar
Security in Vehicle*
Eg: Factory Fitted Immobiliser & Tracking
Use of Vehicle*
Registered Owner*
Registered Owner if Not Proposer
Name ID Number
Main Driver Information*
Name ID Number License Code Year of License
Any Value Added Products Required?*
- None
- Car Hire
- Excess Buydown
- Credit Shortfall / Top Up
Do you require cover for Motor 2?*
- No
- Yes

Vehicle 2*
Year Full Make & Model Value Colour
Non-Standard Extra's
Description Value

Eg. Towbar
Security in Vehicle*
Eg: Factory Fitted Immobiliser & Tracking
Use of Vehicle*
Registered Owner*
Registered Owner if Not Proposer
Name ID Number
Main Driver Information*
Name ID Number License Code Year of License
Any Value Added Products Required?*
- None
- Car Hire
- Excess Buydown
- Credit Shortfall / Top Up

Any Claims in last 5 Years?*
Anything you would like us to be aware of or bring to our attention?
Optional - Current Policy Schedule
Drop files here or

Accepted file types: pdf, jpg, jpeg.
Assists us with comparisons
Consent to Quote*
I confirm that the above information is true and correct
By selecting this box you confirm that all the information given on this form is true and correct. Advice, quotes and premiums are based on this information and is a record of the process undertaken by OneNet, a registered financial service provider FSP5471. If there is anything that you disagree with or do not understand please request further information.

Description	Value

Description	Value

Description	Value