ROA - Personal Insurance - OneNet Health and Insure

Do you require or have cover for your Building?*
- Yes
- No
Are you happy with the current Sum Insured Value*
- Yes
- No
Do you require or have cover for your Home Contents?*
- Yes
- No
Are you happy with the current Sum Insured Value*
- Yes
- No
Do you have Thatch?*
- Yes
- No
Either Roof or Lapa
How Many Geysers do you have - 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
All Risks NOT currently on your Policy Schedule to Add
Description Value
Do you have cover for Motor?*
- Yes
- No

Vehicle 1*
Make & Model Registration Number Colour
Description of 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
Do 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*
Make & Model Registration Number Colour
Description of 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
Do 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 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.
Signature*

Description	Value

Description	Value

Description	Value