Commercial Proposal Form

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Policy Sections Applied For
Fire: YesNo	Public Liability: YesNo
Buildings Combined: YesNo	Employers Liability: YesNo
Business interruption: YesNo	Business All Risk: YesNo
Office Content: YesNo	Electronic Equipment: YesNo
Motor section: YesNo	Machinery Breakdown: YesNo
Theft section: YesNo	Motor Traders: YesNo
Money section: YesNo	Office Assist: YesNo
Glass section: YesNo	Roadside Assist: YesNo
Goods in Transit: YesNo	Car Hire: YesNo
Accidental Damage: YesNo	Self-Insure Fund: YesNo

Supporting Documents Attached (Where Applicable)
Proof of previous insurance: YesNo
Proof of claims history: YesNo
Pre – inspection certificate: YesNo
Proof of tracking unit installation: YesNo
Survey documentation: YesNo

Supporting Documents Attached (Where Applicable)
Proof of previous insurance: YesNo
Proof of claims history: YesNo
Pre – inspection certificate: YesNo
Proof of tracking unit installation: YesNo
Survey documentation: YesNo

Details of Policy Holder
Business name:
Registration number:		Office telephone:
Vat number:		Contact person name:
Type of business:		Contact person nr:
Industry:		Email address:
Address:		Postal address:
Address Code:		Postal address Code:

Claims/Losses Declaration
Are you currently comprehensively insured?:		YesNo
If yes, for how long have you had uninterrupted insurance?
Who is your current insurer?	Policy number:
Who was your previous insurer?	Policy number:
Have you as the insured, or your spouse, or any other person that may be living with you, or any other person that may at any time drive any of the vehicles stated in the policy:
Been declared insolvent, under judicial management, credit counselling?		YesNo
Has any judgment been made against you/ or any person mentioned in the policy?		YesNo
Any criminal convictions, a criminal record or any criminal cases pending?		YesNo
Been refused motor insurance?		YesNo
Has had their driving licence endorsed or suspended?		YesNo
Suffered from any physical defect or infirmity?		YesNo
If Yes, please provide details
Are you aware of any material information, requested or not, that could affect the risk of this proposal?		YesNo
If Yes, please provide details

Full Information Regarding Losses and/or Claims Which Occurred In The Past 3 Years
	Insurer & Policy Number	Description of loss	Date	Amount
1
2
3
4

Cover Information
Insured premises 1
Address Code:
Column 1: Buildings
Column 2: Rent
Column 3: Plant and Machinery
Column 4 Stock and Material in trade
Column 5: Miscellaneous
Description column 5
Business name:
Construction
Roof:
Walls:
Extensions
Special perils extension			YesNo
Leakage extension – First loss value
Leakage extension – Full value			YesNo
Malicious damage extension			YesNo
Riot & Strike – excl. RSA & Namibia			YesNo
Additional claims preparation cost			YesNo
Debris removal			YesNo
Earthquake extension			YesNo
Subsidence and landslip extension			YesNo
Total Sum insured
Insured premises 2
Address Code:
Column 1: Buildings
Column 2: Rent
Column 3: Plant and Machinery
Column 4 Stock and Material in trade
Column 5: Miscellaneous
Description column 5
Business name:
Construction
Roof:
Walls:
Extensions
Special perils extension			YesNo
Leakage extension – First loss value
Leakage extension – Full value			YesNo
Malicious damage extension			YesNo
Riot & Strike – excl. RSA & Namibia			YesNo
Additional claims preparation cost			YesNo
Debris removal			YesNo
Earthquake extension			YesNo
Subsidence and landslip extension			YesNo
Total Sum insured

Buildings Combined Section
Insured premises 1
Address Code:
Construction
Roof:
Walls:
Security
Linked Alarm			YesNo
Alarm not linked			YesNo
Electric Fence			YesNo
Security Doors			YesNo
Burglar bars			YesNo
Subsidence & Landslip			YesNo
Extensions
Subsidence & Landslip			YesNo
Prevention of access -10km			YesNo
Riot and strike – excl. RSA & Namibia			YesNo
Additional claims preparation costs			YesNo
Malicious damage			YesNo
Debris Removal			YesNo
Total Sum insured
Insured premises 2
Address Code:
Construction
Roof:
Walls:
Security
Linked Alarm			YesNo
Alarm not linked			YesNo
Electric Fence			YesNo
Security Doors			YesNo
Burglar bars			YesNo
Subsidence & Landslip			YesNo
Extensions
Subsidence & Landslip			YesNo
Prevention of access -10km			YesNo
Riot and strike – excl. RSA & Namibia			YesNo
Additional claims preparation costs			YesNo
Malicious damage			YesNo
Debris Removal			YesNo
Total Sum insured

1. Business Interruption Section
Cover type options			Sum insured
Loss of gross profit – difference basis(Revenue – variable expenses)
Loss of gross profit – additions basis (Net profit + fixed costs (standing charges) that will remain after claim)
Loss of gross rentals
Wages (weekly basis)
No. of weeks
Please supplay the following information:
Revenue:
Current year	Previous year	Two years ago
Net profit before tax:
Current year	Previous year	Two years ago
Variable Expenses:
Current year	Previous year	Two years ago
Fixed costs:
Current year	Previous year	Two years ago
Extensions and clauses
Specified Suppliers (first tier, direct)	YesNo
Unspecified Suppliers	YesNo
Prevention of Access (10km radius)	YesNo
Customers (first tier, direct)	YesNo
Public utilities – insured perils	YesNo
Accidental damage	YesNo
Claims preparation cost	YesNo
Details of specified suppliers / sub-contractors (Direct, first tier)
Name	General Location	Dependency %





Details of customers (direct, first tier)
Name	General Location	Dependency %

2. Accidental Damage Section
Defined Events:
Property total value	First loss sum insured	Basis %
Extension:
Leakage / Discharge			YesNo
Accidental physical loss of or damage to the insured property caused by discharge or leakage from tanks, pipes or apparatus of chemicals, oils, liquids, fluids, gases or fumes (including loss of such chemicals, oils, liquids, fluids, gases or fumes) other than loss or damage resulting from wear and tear or other gradually operating causes of the tanks, pipes or apparatus.)

3. Office Content Section
Insured premises 1
Address Code:
Total Sum insured
Insured premises 2
Address Code:
Total Sum insured
Extensions
Malicious damage extension	YesNo	R 20 000.00
Riot and strikes	YesNo
Theft	YesNo
Theft by forcible and violent entry/exit	YesNo	R 10 000.00

4. Theft Section
Insured premises 1
Address Code:
Insured premises 2
Address Code:
Item	Basis of cover (please tick) *	Sum Insured
Insured premises 1	Full value basis \| First loss basis
Insured premises 2	Full value basis \| First loss basis
Security:
Insured premises 1
Alarm linked to 24 hr armed response			YesNo
Security gates on all interleading doors			YesNo
Insured premises 1			YesNo
Burglar bars on all opening windows			YesNo
Security complex with 24 hr guards			YesNo
Security:
Insured premises 2
Alarm linked to 24 hr armed response			YesNo
Security gates on all interleading doors			YesNo
Insured premises 1			YesNo
Burglar bars on all opening windows			YesNo
Security complex with 24 hr guards			YesNo
Specified Items
Description	Serial number	Sum Insured
Description	Serial number	Items Sum Insured
Description	Serial number	Items Sum Insured
Description	Serial number	Items Sum Insured
Description	Serial number	Items Sum Insured
Description	Serial number	Items Sum Insured
Description	Serial number	Items Sum Insured

5. Money Section
Money contained in a locked safe or strong room	YesNo
Situated in a building at the insured’s premises covered inside the business hours	YesNo
Extensions
Receptacles	YesNo
Clothing and personal effects	YesNo	R 20 000.00
Locks and keys	YesNo	R 20 000.00
Additional claims preparation cost	YesNo	R 20 000.00

6. Glass Section
Item	Sum Insured
Insured premises 1
Insured premises 2
Extension:
Special replacement (if required by regulation to replace with superior quality glass, the cost difference will be covered)		YesNo

7. Goods In Transit Section
Means of conveyance
Full description of load (what is being transported?)
Commodity class (the transport of highly explosive substances, oil, liquefied gas, chemical substances and gases in liquid, compressed or gaseous states are not covered)
Load limit (the sum insured for each load conveyed
Annual carry (the total value of all loads carried during a year or load limit multiplied by the amount of loads carried per annum)
Cover type
Restricted cover excluding theft(Fire, explosion, collision, derailment and overturning excluding theft & hijack cover)			YesNo
All Risk cover:(Fire, explosion, collision, derailment, overturning including theft & hijack cover)			YesNo
Extensions:
Debris removal cover (environmental clean-up) – R20 000			YesNo
Fire extinguishing charges extension			YesNo
Riot and strike cover (excl. RSA & Namibia)			YesNo

8. Business All Risk Section
Specified Item full description	Serial Number	Insured Amount

9. Public Liability Section
Public liability (max R 10 000 000)
Extensions:
Products liability (max R5 000 000)		YesNo
Defective Workmanship liability (max R5 000 000)		YesNo
Legal defence costs (max R1 000 000)		YesNo
EU Liability (max R1 000 000)		YesNo

10. Employers Liability Section
Limit of Liability		Estimated annual earnings
Category of Employees
All Employees		YesNo
Specified List of Employees		YesNo
If Specified List full names and id numbers:

10. Employers Liability Section
Number of shifts per day?
Normal working hours?
Days worked per week?
Are there any special hazards or circumstances – e.g. mode of operation (computer controlled)? Please provide details:
Is the property insured against fire, explosion etc.? if so, with who?
Is the property insured against machinery breakdown currently? If yes with who?
Have you suffered any losses from fire, storms, machinery breakdown etc. in the last three years? If yes please provide details in terms of: cause, extent of damage and cost:
Machinery details:
Premises	Machinery Description	Replacement value







		TOTAL:
Please list any machines that are still under manufacturer warrantee / guarantee / maintenance contract and indicate such contract expiry date:
Premises	Machinery Description	Expiry date or warrantee etc.






Please provide name and contact number of maintenance / service company:

Maintenance & servicing need to be done in accordance with manufacturer specification or recommendation by approved providers.
Machinery breakdown (Loss of profits)		YesNo
Deterioration of stock following machinery breakdown		YesNo
If deterioration of stock following machinery breakdown is selected, please complete the following:
Number of cold rooms / deep freeze rooms?
Are they fitted with external temperature monitoring gauges?
What are the normal operating temperatures of the rooms?
How long can rooms hold temperature before deterioration of stock occurs?
Extensions:
Capital Additions		YesNo
Overtime, night work, work on public holidays		YesNo

12. Motor Section
Type of Vehicle:
Vehicle 1
Sedan / Hatch / Coupe / SUV		YesNo
LDV / Pick Up		YesNo
Road Motorcycle		YesNo
Off road Motor cycle		YesNo
Quad Bike		YesNo
Year of Manufacture
Make and Model
Engine Number
Vin Number
Registration Number
Registered owner full names
Registered owner id number
Please select basis of cover		Open driverNamed driver
Regular Driver Name
Regular Driver ID no
Regular Driver NCB / CFG
Occupation of driver
Year licence obtained (mmyyyy)
Interest of Financial Institution
Type of use		PrivateBusinessCommercial
Please provide description of use:
Security Fitted in vehicle(Tracking units need to be installed within 14 days from inception otherwise cover will be limited to 3rd party cover)		Approved tracking unitTracking unit to be installedAlarm VESA approvedImmobiliser VESA approved
Modified or code 3 vehicle		YesNo
Non- Factory fitted Accessories:	Item description	Value
	Item description	Value
	Item description	Value
	Item description	Value
	Item description	Value
Vehicle 2
Sedan / Hatch / Coupe / SUV		YesNo
LDV / Pick Up		YesNo
Road Motorcycle		YesNo
Off road Motor cycle		YesNo
Quad Bike		YesNo
Year of Manufacture
Make and Model
Engine Number
Vin Number
Registration Number
Registered owner full names
Registered owner id number
Please select basis of cover		Open driverNamed driver
Regular Driver Name
Regular Driver ID no
Regular Driver NCB / CFG
Occupation of driver
Year licence obtained (mmyyyy)
Interest of Financial Institution
Type of use		PrivateBusinessCommercial
Please provide description of use:
Security Fitted in vehicle(Tracking units need to be installed within 14 days from inception otherwise cover will be limited to 3rd party cover)		Approved tracking unitTracking unit to be installedAlarm VESA approvedImmobiliser VESA approved
Modified or code 3 vehicle		YesNo
Non- Factory fitted Accessories:	Item description	Value
	Item description	Value
	Item description	Value
	Item description	Value
	Item description	Value
Extensions:
Third party Liability		YesNo	R 2 500 000
Glass		YesNo	R 10 000
Keys and locks		YesNo	R 10 000
Wreckage removal		YesNo	R 10 000
Credit shortfall required		YesNo	10% of Retail20% of Retail
Passenger liability required		YesNo	R 1000 000
Unauthorised passenger liability		YesNo	R 1000 000

13.Motor traders section
Motor Traders Internal	YesNo
Motor Traders Internal	YesNo
External cover basis:
Comprehensive
Third party fire and theft
Third party only
Extensions:
Use of car hoists	YesNo
Loss of use of customers vehicles	YesNo
Use for social domestic and pleasure	YesNo
Unauthorised use by employees	YesNo
14.Caravan/ Trailer Section
Type of Caravan/ trailer		CaravanTrailer (flatbed/goods)Off road camping trailer
Year of Manufacture
Make and Model of the Caravan / Trailer
Agreed Value
Comments