Personal Insurance Application
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Personal Insurance Application
HFM IB (Pty) Ltd | FSP 46470
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Financial Portfolio Manager
Application created by
Application created for
Link to lead reference
Broker fee (R)
The policyholder gives consent for an ITC / credit check to be done.
The policyholder or anyone to be insured has previously been cancelled or refused for unpaid premiums, multiple claims or fraud.
Details of cancellation / refusal
Insured Details
+ Add co-insured
Insured Addresses
Capture each property once. Building and contents covers below pick from this list and inherit all details.
+ Add address
Insurance History
Current insurance status
Select...
Currently insured
Break in cover
First time insurance
Consecutive insurance history
Select...
Less than 1 year
1 - 2 years
3 - 5 years
5 - 10 years
More than 10 years
Current insurance company
When did you join this insurer
Current premium (R)
How long without cover
Last insurance company
Losses 0-12 months
Losses 12-24 months
Losses 24-36 months
Losses 36-48 months
Losses 48-60 months
Reason for shopping around
Looking for a better premium
Looking for better cover
Premium increase at renewal
Poor service from current insurer
Claim dispute / rejected claim
Consolidating policies
New purchase / first time insurance
Other (see broker notes)
Motor Section
+ Add vehicle
Home Cover
Add a cover per type: buildings and contents are separate covers with their own sums insured, each linked to an address above.
+ Add building / contents cover
Portable Items / All Risk
+ Add portable item
General Broker Notes
Submit application
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Application submitted
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