Personal Information
Email Address:
 Your Broker's Name:
Insured's Name:
 Residential Postal Code:
Principle Driver Information
Name:
 Occupation:
ID No.:
 Gender:
Age:
 Tel No.:
Years with Drivers License:
 How many years driving a 4x4:
Claims History
Please detail all MOTOR CLAIMS you have had in the past 3 years:
Please detail all LOSSES/CLAIMS (i.e householders, all risks etc) you have had in the past 3 years:
Vehicle Details
Use of Vehicle:
Overnight Parking:
Registration Year:
 Make & Model:
*Vehicle Retail Value:

*Minimum sum insured of vehicle R70 000, excluding accessories. Maximum sum insured R1 000 000 unless agreed by Cross Country in writing. We will not insure the vehicle if the driver of the vehicle is residing in a territory outside the border of the RSA.

Value of Accessories:
Total Value:
 Would you like to specify any audio equipment:
Discount Applicators
Tracking Device Installed: (tick if Yes) 
Type of Tracking Device:
*Tick each question below if 'Yes'
Has the principal driver completed a Cross Country ON/OFF road driving course? 
Is the driver a Bona Fide Pensioner - non working with no additional income? 
Voluntary Basic Excess of 5% of claim, minimum R5000? 
Do you or any principal driver of the insured vehicle have or have had any judgements against you? 
Have you or any principal driver of the insured vehicle ever had an insurer declined or cancel a policy? 
Car Hire Required:
Where did you hear about Cross Country?
Other:
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