personalinsurance ROA – Personal Insurance Step 1 of 5 20% Name* First Last Contact Information*Contact NumberEmail AddressID NumberMarital Status*Full Physical Address* Street Address Address Line 2 City ZIP / Postal Code Do you require or have cover for your Building?* Yes No Value of BuildingDo you require or have cover for your Home Contents?* Yes No Value of ContentsDo you have Thatch?* Yes No Either Roof or LapaHow Many Geysers do you have – Select Applicable 1 – One 2 – Two 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, JewelleryAll Risks RequiredDescriptionValue Do you need cover for Motor?* Yes No Vehicle 1*YearFull Make & ModelRegistration NumberColourDescription of Non-Standard Extra'sDescriptionValue Eg. TowbarSecurity in VehicleEg: Factory Fitted Immobiliser & TrackingUse of Vehicle*Private – Including to and from WorkProfessional – Occasional Client VisitsBusiness UseRegistered Owner*ProposerOtherRegistered Owner if Not ProposerNameID NumberMain Driver Information*NameID NumberDo you have or need Value Added Products?* No – Not Required Car Hire Excess Buydown Credit Shortfall / Top Up Do you have cover for Motor 2?* No Yes Vehicle 2*YearFULL Make & ModelRegistration NumberColourDescription of Non-Standard Extra'sDescriptionValue Eg. TowbarSecurity in Vehicle*Eg: Factory Fitted Immobiliser & TrackingUse of Vehicle*Private – Including to and from WorkProfessional – Occasional Client VisitsBusiness UseRegistered Owner*ProposerOtherRegistered Owner if Not ProposerNameID NumberMain Driver Information*NameID NumberDo you have or need any Value Added Products?* No – Not Required Car Hire Excess Buydown Credit Shortfall / Top Up Anything you would like us to be aware of or bring to our attention?Confirmation* The above information is true and correctBy 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.Signature
