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PERSONAL DETAILS

Title
First Name
Last Name
Email
Mobile Number
Landline o/h
ID Number
Date of Birth
Occupation
Marital Status
Nominated Rider Name
Nominated Rider Date of Birth


MOTORCYCLE DETAILS

Year
Make
Model
Engine Capacity
Sum Insured
Is bike kept in locked Garage?
Address where bike is kept


LICENSING DETAILS

Licence type
(If licence) Date that licence was obtained
(If learners) Is this your first learners?
(If learners) Date learners obtained
Claims in last 5 Years?
Are you currently Insured for a motorcycle?


GENERAL QUERIES

How did you hear about Diamonds and Dust?
Do you have any Questions?



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