Form - Motorite

For a speedy quote

or call our telesales quote line
on 011 612 5301

*First Name:
*Surname:
*Phone Number:
*Fax Number:
*Email Address:
Is your Vehicle Currently Financed?	yes No
Which Bank Financed your vehicle?
Vehicle Make:
Vehicle type:
Passenger Car
Light Commercial
Taxi/ Public Transport
Truck
Model Description:
Year of Registration	Day: Month: Year
Current Kilometer Reading:
GVM(Trucks):
Does this Vehicle have a Current Plan?
Yes No
If yes above, who is the plan with?(if it is with Motorite please add policy number)

What type cover would you require for you vehicle?
Mechanical Breakdown Warranty
Service Plan
Full Maintanance Plan
Service History
Does the Vehicle have an up to date service record?
Yes No
If yes above, where are the services done?
Manufacturers approved dealer
Bosch servive center
Shell auto serv.
Moto lube
Other

Motorite Insurance Administrators is a Licensed Financial Services Provider. (No: 9140)

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