Personal Information
Email Address:
Your Broker's Name:
Insured's Name:
Residential Postal Code:
Principle Driver Information
Name:
Occupation:
ID No.:
Gender:
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Male
Female
Age:
Tel No.:
Years with Drivers License:
How many years driving a 4x4:
Claims History
Have you had any Motor Claims in the past 3 to 7 years: (tick if Yes)
Previous Losses:
Vehicle Details
Use of Vehicle:
Private (incl. to and from work)
Limited Business Use (max. 3 calls to clients per day - no carriage of goods)
Full Business Use (Sales, site visits, brokers, estate agents etc. - no carriage of goods)
Overnight Parking:
Locked Garage
Secure Carport
None of the above
Registration Year:
Make & Model:
Vehicle Retail Value:
Value of Accessories:
Total Value:
Would you like to specify any audio equipment:
Discount Applicators
Tracking Device Installed: (tick if Yes)
Type of Tracking Device:
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Bandit – 15% discount on premium
Neo Track – 15% discount on premium
Other Tracking Device with Automatic Activation - 5% discount on Premium
Other Tracking Device with Manual Activation - 0% discount on Premium
Any Off Road Training Courses completed: (tick if Yes)
(Certificate Required)
Any On Road Training Courses completed: (tick if Yes)
(Certificate Required)
Is the Principle Driver over 55 years of age: (tick if Yes)
Car Hire Required:
No
Group B Vehicle
4 X 4 Vehicle
Where did you hear about Cross Country?
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Website
Friends
Magazine
4x4 Club
Other (Please specify below)
Other:
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