Motor Insurance - Stanbic Bank Zimbabwe

Zim National ID

ID Number (format: 12-345678X90):*

Ooops, You captured a Wrong ID Number! Try Again. Re-check that the format (eg: 12-345678X90) you entered is correct.

Date of Birth*

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Details of Proposer

First Names*

Provide your first name(s) as in your government-issued ID.

Last Name*

Provide your last name as in your government-issued ID.

Occupation

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Home Address*

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Suburb*

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City/Province/Town*

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Mobile Number (format: 123456789)*

Exclude international code. Only nine (9) digits are accepted.

Telephone (Work)

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Telephone (Home)

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Email address

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Select Delivery or Branch Collection

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Delivery Address (A fee may be applicable)

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Preferred Branch*

Select the branch you opened your account with

Stanbic Bank account number*

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Insurance Package

Insurer*

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Motor insurance package

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Select package option

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Select renewal term

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Insurance policy currency*

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Period of insurance from

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Period of insurance to

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Do you have a valid license to drive this class of vehicle?*

YesNo Invalid Input

Date when licensed

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If you do not have a valid license, who will be driving the vehicle?

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Details of relationship and license details

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Do you, or the person who will be driving the vehicle, suffer from any physical disability or infirmity?

YesNo Invalid Input

Give details

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Have you, or the person who will be driving the vehicle, been convicted of any motoring offense?

YesNo Invalid Input

Give details

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Details of any accidents, losses or claims during the past 3 years

Date of loss

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Amount paid/outstanding

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Date of loss

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Amount paid/outstanding

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Date of loss

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Amount paid/outstanding

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Vehicle details

Make/model

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Registration number

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Year of make

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Indicate use of vehicle*

PrivateBusiness Invalid Input

Currency *

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Estimated Value

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Indicate vehicle mass (kg)

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Customer declaration

Name accessories

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Value of accessories

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Name accessories

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Value of accessories

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Name accessories

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Value of accessories

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Name accessories

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Value of accessories

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Any other valuable information about the vehicle/driver(s)

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I/we declare that the information provided above is true, correct and complete and that it contains all information known to me/us that will affect the risk to be insured. This statement, and any other written statement made by me/us or on my/our behalf for the purpose of insurance, will be the basis of and will be incorporated in the contract between me and the Insurance Company that I have chosen from the panel of Insurance Companies provided to me.

I/we further agree to accept insurance on the terms and conditions set forth in the Company's policy and undertake to notify the Company immediately if the risk changes. I/we also agree that this agreement will take effect from the date of receipt of the premium payment.

I authorise the bank to debit my account number with the premium amount.

Proposer’s signature:*

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ID Number (format: 12345678X90)::

Date of Birth:

First Names:

Last Name:

Occupation:

Home Address:

Suburb:

City/Province/Town:

Telephone (Home):

Telephone (Work):

Mobile Number (format: 123456789):

Email address:

Select Delivery or Branch Collection:

Delivery Address (A fee may be applicable):

Preferred Branch:

Stanbic Bank account number:

Insurer:

Motor insurance package:

Select package option:

Select renewal term:

Insurance policy currency:

Period of insurance from:

Period of insurance to:

Do you have a valid license to drive this class of vehicle?:

Date when licensed:

If you do not have a valid license, who will be driving the vehicle?:

Details of relationship and license details:

Do you, or the person who will be driving the vehicle, suffer from any physical disability or infirmity?:

Give details:

Have you, or the person who will be driving the vehicle, been convicted of any motoring offense?:

Give details:

Date of loss:

Amount paid/outstanding:

Date of loss:

Amount paid/outstanding:

Date of loss:

Amount paid/outstanding:

Make/model:

Registration number:

Year of make:

Indicate use of vehicle:

Currency :

Estimated Value:

Indicate vehicle mass:

Name accessories:

Value of accessories:

Name accessories:

Value of accessories:

Name accessories:

Value of accessories:

Name accessories:

Value of accessories:

Any other valuable information about the vehicle/driver(s):

I confirm that I have read the Terms and Conditions governing the granting of credit facilities, and agree to be bound by them should my loan application to be approved.*

I declare that the information provided by me is complete and correct and I accept the terms and conditions overleaf. Please read and agree to the Terms & Conditions. It provides you with important information about your application.

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timestamp

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Date

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