PRIVATE MOTOR PROPOSAL FORM Head Office, Insurance Centre, 30 Samora Machel Avenue, P.O. Box 1256, Harare, ZimbabweTel: 263-4-701133, 704911-4, 700346, Fax: 263-4-704134, 700083 Please enable JavaScript in your browser to complete this form. – Step 1 of 3SURNAME and FIRST NAME MrMrsDrDATE OF BIRTH:OCCUPATIONID NUMBERE-MAIL ADDRESS *TELEPHONE: HOMEWORK CELLPOSTAL ADDRESSRESIDENTIAL ADDRESSBANK DETAILSBANK ACCOUNT NOPERIOD OF INSURANCEFromToNextDETAILS OF PROPOSERAre you fully licenced for this class of vehicleYesNoDate when licencedHave you ever been denied or have insurance policy cancelledYesNoIf yes to the above , state the reasonName of previous insurerState any loss suffered for the past 3years and their monetary valueNextVEHICLE (S) DETAILSMake/ModelEngine & Chassis No: Year of make Reg No:Type of coverValue To be insured(incl.accessories)Make/ModelEngine & Chassis No: Year of make 2.Name2.Engine & Chassis No: 2.Year of makeReg No: Type of cover Value To be insured(incl.accessories)2.Reg No:2.Type of cover2.Value To be insured(incl.accessories)MessageSubmit