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Motor Private Proposal
Step
1
of
2
50%
First Name/s
(Required)
Surname
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
ID Number
(Required)
Cell Phone Number/s
(Required)
Email Address
(Required)
Marital Status
(Required)
Married
Single
Divorced
D/L Number
(Required)
Date of Issue
(Required)
MM slash DD slash YYYY
Place of Issue
(Required)
Harare
Chi Twn
Masvingo
Blwyo
Gweru
Kadoma
Mutare
Chinhoyi
Kwekwe
Other
Home Address
(Required)
Period Of Cover
From
(Required)
MM slash DD slash YYYY
To
(Required)
MM slash DD slash YYYY
Renewable
(Required)
Monthly
Quarterly
Termly
Bi-Annually
Annual
DETAILS OF THE VEHICLE(S) TO BE INSURED
(Required)
Vehicle Make
Vehicle Model
Year of Manufacture
Registration Number
Engine Number/Chassis No.
Estimate of Present Value incl. Accessories
Insurance Type ((RTA/ FTP/ FTPFT/Comprehensive)
Details of accessories if any (e.g Radios)
Add
Remove
Have any of the above listed drivers been involved in an accident, loss or claim in the past 3 years or license suspended?
(Required)
Yes
No
Provide details
(Required)
Have any of the above listed drivers been declined motor insurance, had a motor policy cancelled or extra terms imposed for any reason?
(Required)
Yes
No
Provide details
(Required)
Have any of the above listed drivers any conviction for careless, reckless driving, driving under influence of alcohol in the past 2 years?
(Required)
Yes
No
Provide details
(Required)
Have any of the above listed drivers listed suffering from any physical, defective vision or hearing or mental infirmity that may affect his/her ability to drive?
(Required)
Yes
No
Provide details
(Required)
Will the car be driven frequently by a driver who is under the age of 30 years and/or less than 5 years driving experience?
(Required)
Yes
No
Provide details
(Required)
Usage of the vehicle
(Required)
Private Use
Business Use
Private & Business
Commercial Use
Previous Insurance Company
Policy Number
Declaration
(Required)
I agree.
I/We agree that this proposal shall be the basis of the contract between me/us and AFC Insurance Company. I/We declare that the statements made in this proposal
are true and correct to the best of my/our knowledge and belief and I/we agree to accept and abide by the AFC Insurance Company’s form of policy for the risks now
proposed.
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
About AFC Holdings
Institutional Overview
Vision, Mission & Values
Board Of Directors
Executive Management
Investments
Tenders
Careers
Commercial Bank
Land & Development Bank
Leasing
Insurance
Media Centre
Press Release
Gallery
News & Updates
