Dirtsure Quote Personal InformationName* First Last Email* Enter Email Confirm Email Broker's Name*Postal Code*Quote DetailsInsured's Name* First Last Insured's Occupation*Identity Number*Phone*Gender*-- Please Select --MaleFemaleJudgments*Does the insured have any judgments on their name?-- Please Select --YesNoCancelled Insurance*Has the insured ever been refused insurance or have insurance cancelled by the insurer for any reason?-- Please Select --YesNoCover Required*Please specify which cover you would like to quote for. 4x4 Vehicle All Risks Caravan & Trailers Classic Cars Dirt bike/Quad Bike Home Contents House Owners Marine Motor Vehicle Motorcycle Define Principle Driver*-- Please Select --Different Principle DriverSame as AbovePrincipal DriverName First Last Driver's Age*License*Age of driver's licenseVehiclesList*Add your vehicles/bikes here. Click the plus icon to add a new line.Year of RegistrationMake & ModelRetail ValueUse of VehicleOvernight ParkingSum of Accessories Tracking Device*Do all the above vehicles have a tracking device?-- Please Select --YesNoTracking Device Company*Please add the vehicle and type of tracking device below. VehicleTracking Device Cross Border Cover*Will any of these vehicles be taken across the border?-- Please Select --YesNoCross Border Territories*Please state which vehicle(s) will be taken to which territoriesVehicle DescriptoinTerritoryExpected Date Marine Skipper DetailsSkipper's Name* First Last Skipper's Identity Number*Skipper License*Does the skipper have a valid license?-- Please Select --YesNoSkipper's Residential Address* Street Address City Province Postal Code Marine VesselsVessel Details*List your vessels here. Click the plus icon to add a new vessel.Make/ModelYear BuiltHull TypeSerial #Date PurchasedPurchased From?Sum Insured Buoyancy*Do all the above vessels have a valid buoyancy?-- Please Select --YesNoVessels without buoyancy*List all vessels without a valid buoyancy Seaworthy*Do all the vessels above have a valid seaworthy certificate?-- Please Select --YesNoVessels without seaworthy*List all the vessels that don't have a valid seaworthy certificate Moorings*Where is boat kept when not in use?Inland watersAt seaLocked garageEnclosed locked carportOff-road on propertyOn road (chained)Behind locked gatesAfloat on moorings - securedNon-secure storageMarina*If moored please state the name of the Marina and whether they are professionally laid and maintained and securedSecurity at Marina*Launch Site*Where will your vessels be launched?Established Launch SiteBeach/Surf LaunchDifferent Launch Sites*How often will your vessel(s) be launched away from the usual launch site?Vessel Use*Where are the vessels used?Inland & CoastalInland OnlyCross Border*Will the vessel(s) be used outside of the borders of R.S.A?-- Please Select --YesNoTerritories*Please advise the territories these vessel(s) will be taken to. VesselTerritory Hire Purchase*Are any of the vessel(s) or motors subject to hire purchase?-- Please Select --YesNoHire Purchase Details*Provide details of the hire purchase on these vessel(s) and/or motorsVessel/Motor DetailsCompany/BankHire Purchase Amount Home Contents & House OwnersHouseowners Cover*The sum insured required for your buildingHousehold Cover Required*Amount of sum insured for the contents inside your home.Please enter a value greater than or equal to 50000.All Risk*Please specify items such as computers, cellphones, laptops, jewellery.Item Description (eg: Apple MacBook)Replacement Value Value Added ProductsDo you require IVP?*Pays the difference between retail value at inception, and retail value at date of loss.-- Please Select --YesNoDo you require Xs Sure?*Flat R1000 excess for basic accident, theft/hijack, water and rollover-- Please Select --YesNoDo you require Tyre Sure?*Insurance for tyres.-- Please Select --YesNoDo you require Car Hire?*-- Please Select --Yes - Group B (1400 Sedan)Yes - Group D (Automatic)Yes - Soft 4x4No Car Hire RequiredDo you require extended repatriation?*-- Please Select --Yes - R50,000No - (R35,000 automatically included)Do you require HP shortfall?*-- Please Select --YesNoDisclaimersTransunion ITC Check*I hereby consent that an enquiry can be done at inception of the policy or within the duration of the policy, with any registered credit bureau on my credit and insurance profile in order to assess and underwrite the risk fairly. Yes Broker Referral*Should you require, we can refer you to a list of brokers in your area. Yes, refer me a broker No, I have my own broker Broker Required*Please note that this is an indicative quote only. As CCIC is a UMA, you will be required to go through a broker when placing business with us. I Understand EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.