Request for Insurance Substitution
Welcome to the SA Taxi Insurance Substitution form.
Please complete the following fields and upload the necessary documentation.
Insurer Details
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| I am from* [select* Insurer include_blank “Insurance 1” “Insurance 2” “Insurance 3” “Insurance 4”] |
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| My Email is* [email* your-email] |
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Client Details
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| Client Name* [text* your-name] |
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| Client Surname* [text* Surname] |
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| Client ID Number* [text* IDNumber] |
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| Client Cellphone* [number* Cellphone] |
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| Broker Name* [text BrokerName] |
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| Client Deal Number* [text DealNumber] |
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| Client vehicle year is* [select* VehicleYear include_blank “2007” “2008” “2009” “2010” “2011” “2012” “2013” “2014” “2015” “2016” “2017”] |
Client vehicle make is* [select* VehicleMake include_blank “Altego” “Audi” “Cam” “Chevrolet” “Cmc” “Fiat” “Force Traveller” “Ford” “Foton” “Hyundai” “Isuzu” “Iveco” “Jeep” “Jinbei” “Kia” “King Long” “MAN” “Mercedes” “Nissan” “Other” “Peugot” “Polar Sun” “TATA” “Toyota” “VW”] |
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| Client Vehicle Model is* [select* VehicleModel include_blank “Altego” “A4” “Inyathi” “Indlovu” “Utility” “Amandla” “Sesbuyile” “Ducato” “Traveller” “Ranger” “Foton” “Accent” “35 Seater Bus” “KB250” “KB240” “KB300” “Iveco” “Iveco 14v” “Iveco 15v” “Iveco 13v” “Jeep” “Siyavaya” “Kia” “King Long” “MAN” “Sprinter 308” “Sprinter 309” “Sprinter 416” “Sprinter 313” “Sprinter 518” “Sprinter 208” “Sprinter 315” “Sprinter 515” “Vito” “Sprinter” “Sprinter 412” “Sprinter 519” “Sprinter Viano” “Interstar” “Hardbody” “NV350” “NP200” “Other” “Boxer” “Polar Sun” “TATA” “Hilux” “Corolla” “Dyna” “Siyaya” “Quantum” “Toyota GL Diesel” “Avanza” “Condor” “Sesfikile” “Hino” “Panelvan” “Toyota GL Petrol” “Quantum GL” “Crafter” “Vw Crafter 50 80kw Lwb” “Vw Crafter 50 80kw Mwb” “Vw Crafter 35 80kw Mwb” “Vw Crafter 50 120kw Lwb” “Vw Crafter 50 120kw Mwb”] |
Client vehicle year is* [select* VehicleYear include_blank “2007” “2008” “2009” “2010” “2011” “2012” “2013” “2014” “2015” “2016” “2017”] |
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| Client vehicle vin/chassis/engine number is* [text* VinNumber] |
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| Client Premium is [text* Premium] |
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| Effective date of substitution* [date* EffectiveDate “yyyy-mm-dd”] |
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Required Documents
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| [file* Document1] | [file* Document2] | |
| [file* Document3] | [file* Document4] | |
Checklist
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| [checkbox checklist “Comprehensive Motor”] | [checkbox checklist “Abscondence Cover”] | |
| [checkbox checklist “Violation Cover”] | [checkbox checklist “Credit Shortfall”] | |
| [checkbox checklist “Loss of Use”] | [checkbox checklist “Passenger Liability”] | |