Apply for Short Term Insurance

The Short Term Insurance risk assessment tool enables 3 x 2 to assess your general risk profile of a prospective client. A low score on this assessment means that you have relatively low risk profile, and that Momentum Short Term Insurance will very likely be able to offer you the best deal in the market.

Based on the supplied information 3 x 2 Financial Services will provide you with a quote.

* Fields are mandatory.

Title: *

Name: *

Email Address: *

Office Number: *

Cell Number: *

Gender: *

Date of Birth (mm/dd/ccyy): *

RSA ID Number: *

Marital Status: *

Occupation: *

Residential Adress

Address: *

Suburb: *

Postal Code:

Insurance History

Current Insurer:

Any claims in the past 5 years?: *

If yes, what type of claim? (List all claims over past 5 years)

Risk Profile Assessment

1. Current Insurance Details *

2. Previously cancelled for poor claims experience or non-payment of premiums, or advised to seek alternative insurance? *

3. Regular driver: number of vehicle thefts, hijackings or accident claims/incidents in the last three years. *

4. Type of vehicle: is the vehicle a “pocket rocket” (eg Golf GTI, Toyota RSI, Opel GSI, Mini Cooper S, Renault Clio Sport, Peugeot 206 GTI)? *

5. Colour of the vehicle. *

6. Vehicle Use *

7. Vehicle mileage per annum *

Descript of Any Other Cover Required: