Age |
|
Driving Experience (Number of Years) |
|
Previous / Current Insurer |
|
No Claim Discount % |
|
Do you have any other business with Maritime? |
Yes
No |
Are you a member of:
(Check all that apply) |
TTUTA
TAA
PSA |
No. of Accidents/Losses in last 3 years (if any) example: Theft, Flood etc
Details of Accidents/Losses (Date, Type) and Amounts Paid |
|
Do you have any physical impairments? |
Yes
No |
If Yes, please state |
|
What date do you need insurance from? |
|
Vehicle Registration Number: |
|
Make and Model: |
|
Age of Vehicle / Year of Manufacture: |
|
Current Market Value of Vehicle |
|
Engine Size: Cubic Capacity (C.C.) / Horsepower (H.P.) |
|
Anti-Theft details:
(Immobilizer / Alarms must have at least 3 immobilization points) |
Alarms
Immobilizer
Multilock
Car Search |
Has the vehicle been modified? |
Yes
No |
If yes, please give details |
|
Does the vehicle have any accessories other than that supplied by the manufacturer? Example: Mag rims, stereo, C&G, others |
Yes
No |
Please state what these accessories are: |
|
Will the vehicle be used solely for private purposes? |
Yes
No |
If No, please give details of use: |
|
Car is: |
Left-Hand Drive
Right-Hand Drive |
|
Local
Foreign Used / Roll-on Roll-off |
Will the vehicle be driven by anyone under the age of 25 or anyone with less than 2 years driving experience? |
Yes
No |
If Yes, please give details of driver: |
Name:
Age:
Occupation:
Driving Experience:
Accidents / Losses:
|
Type of coverage required: |
Third Party
Third Party Fire & Theft
Comprehensive
|
What Extra Coverage Do You Require: |
Increased W/Screen
2500
4000
5000
7500
Riot, Strike & Civil Commotion
Flood & Other Perils of Nature |
