Request a Quote - Freisenbruch

Customer type*

New Client
Existing Client

Is this a renewal request?

Renew current policy

Basic information

Name*

Phone number*

Email address*

How did you hear about us?

Type of cover required:*

Insurance History

Please indicate below whether you or any member of your household…

Suffered loss during the last 5 years from any of the risks that you now wish to insure?*

Yes
No

Have been refused insurance or had special terms or conditions applied by an insurer for any of the risks that you now wish to insure?*

Yes
No

Have been convicted of or have any prosecution pending for any criminal offence (excluding traffic offences)*

Yes
No

Details*

Please provide full details here:

Home Insurance Details

Home Address*

Required Cover*

Building
Contents

Rebuild Value*

Value of Contents*

(Contents which do not leave your home)

Motor Insurance Details

Name of Registered Owner*

Date of Birth*

Vehicle Registration Number*

Vehicle Type*

Vehicle Make*

Vehicle Model*

Engine Capacity*

Vehicle Manufacture Year*

Coverage*

Comprehensive
Third-Party Only

Vehicle Value*

Recent Claims/Offences

If you have had any claims or traffic offences in the last 5 years, please explain here. Otherwise, leave this field blank.

Marine Insurance Details

Name of Vessel*

Age of Vessel*

Vessel Description*

(Type, builder, length)

$ Sum Insured*

Engine Details*

Use of Vessel*

Mooring Location*

Owner/Operator Experience*

Additional Information

Details/Comments

Provide any additional information here.

Signature

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Comments

This field is for validation purposes and should be left unchanged.