Classic Car Insurance Quote

1

2

3

4

Client Details

Company Name (Optional)

Company Registration Nr (Optional)

Full Name of Proposer *

Date of Birth *

ID or Passport *

Email *

Contact Number *

Address

Street Address *

Suburb *

City *

Provence / State *

Postal Code *

Country *

Postal Address

* If different from the Physical Address

Street Address

Suburb

City

Provence / State

Postal Code

Country

2

3

4

Driver Details

ONLY FILL OUT RELEVANT INFORMATION IF YOU ARE BOTH THE CLIENT & THE DRIVER.

Number of Drivers *

Title *

First Name

Last Name

Date of Birth

ID or Passport

Gender *

Marital Status *

Driver's License Code *

Date of First Issue for License *

Years Claim-free *

Driver CHG (Claim Free Group)

3

4

Car Details

Make *

Model *

Year *

Registration *

Vehicle Value *

Accessories Value *

Mileage *

Drive *

Existing Security *

Usual Daytime Parking *

Overnight Parking *

Cover Type *

4

Claim History

Date of Claim Event

Amount Claimed

Description of EventClaims History (Provide details of any vehicle losses in the last 5 years)

Has any Insurer ever refused, cancelled or declined to renew any policy held by you or an individual who will be covered by this policy? *

Yes

No

Existing Policy

Current Insurer

Date of Renewal

Policy Nr.

GENERAL

‍

- Vehicles must be registered in the Republic of South Africa.

‍

- This quotation is inclusive of VAT and SASRIA, but excludes broker fees.

‍

- This quotation is subject to the terms, exceptions, conditions, limits of indemnity/sum insured and standard excesses of the company’s standard motor policy.

‍

INFORMATION SHARING DECLARATION

‍

It is necessary for insurance companies to share information in order to underwrite (assess and price the risks) policies fairly and lower the number of fraudulent claims.In view of the above, I/we (and any person representing me) declare by the submission and/or signing of this document to:

‍

- Accept that it is in the public interest for insurers to share insurance information (including credit information).

‍

- Consent to my policy, claims or credit information being verified or shared with third parties in the ordinary course of business.

‍

- Accept that any information provided to the insurer may be stored in a shared database.

‍

- Consent to such information being given to any other insurance company and/or reinsurance company or its agent should there be a legitimate business reason for doing so.

‍

- Accept that this information may be checked against other legal sources or databases.

‍

- Confirm that all information provided is true, correct and complete.

‍

I have read and agree to the terms of the Basseille Investment Group customer agreement. *

Basseille Classics may process my data *

For more information on how we use your data, refer to our Privacy Policy.