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    Good Faith

    We believe in treating all policyholders fairly and to act professionally, honestly and with due care and diligence. We also rely on the honesty and integrity of our policyholders in this mutual partnership to help us accurately assess risk and determine premium. We underwrite risk based on the information provided to us at quote stage, at policy inception stage as well as every time circumstances change that could affect your risk in any way. This document, your policy schedule, all declarations, communications and proposals made by you, or on your behalf forms part of the insurance contract that will be the reference point when assessing claims.

    Brokerage name

    Quotation number

    Broker name

    Broker Telephone number

    Broker Id number

    Broker email address

    Policy Sections Applied For

    Buildings/Homeowners

    Personal Liability

    Householders/Content

    Personal Computers

    Motor

    Personal Accident

    Motorcycles

    Hybrid Help

    Caravans & Trailers

    Crime Assist

    Watercraft

    Car Hire

    All Risk

    Self-Insure Fund

    Supporting Documents Attached (where Applicable)

    Proof of previous Insurance

    Proof of claims history

    Pre-inspection certificate

    Survey documentation

    FICA (if Self-Insure fund selected)

    Personal Details Of Policy Holder

    Title

    Full Names

    Surname

    Marital Status

    Occupation

    RSA citizen?

    If no which country?

    ID Number

    ID Number

    Tel No. (W)

    Tel No. (H))

    Fax No

    Cell No

    Email Address

    Address

    Code

    Claims/Losses Declaration

    Are you currently comprehensively insured?

    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

    a) Been declared insolvent, under judicial management, credit counselling

    b) Has any judgment been made against you/ or any person mentioned in the policy?

    c) Any criminal convictions, a criminal record or any criminal cases pending

    d) Been refused motor insurance

    e) Has had their driving licence endorsed or suspended

    f) Suffered from any physical defect or infirmity

    If Yes, please provide details

    Are you aware of any material information, requested or not, that could affect the risk of this proposal?

    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/Claim

    Date

    Amount

    1

    2

    3

    4

    5

    6

    7

    8

    Cover Information

    1. Building / Homeowners

    Residence 1 Address

    Address Code:

    Property use (tick appropriate option):

    Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune

    Construction and property type:

    Roof:

    Walls:

    Type of property

    Security:

    Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)

    Full subsidence & Landslip cover? (If yes, please note that a geo survey will be required)

    General information: Unoccupied more than 60 days p/a?

    Unoccupied more than 30 consecutive days during any year?

    Unoccupied more than 7 consecutive days in first 45 days of cover?

    Sum insured Required

    Residence 2 Address

    Address Code:

    Property use (tick appropriate option):

    Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune

    Construction and property type:

    Roof:

    Walls:

    Type of property

    Security:

    Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)

    Full subsidence & Landslip cover? (If yes, please note that a geo survey will be required)

    General information: Unoccupied more than 60 days p/a?

    Unoccupied more than 30 consecutive days during any year?

    Unoccupied more than 7 consecutive days in first 45 days of cover?

    Sum insured Required

    2. Content Section

    Residence 1 Address

    Address Code:

    Property use (tick appropriate option):

    Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune

    Construction and property type:

    Roof:

    Walls:

    Type of property

    Security:

    Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)

    Accidental Damage

    Sum Insured

    Subsidence & Landslip

    Current NCB/CFG:

    General information: Unoccupied more than 60 days p/a?

    Unoccupied more than 30 consecutive days during any year?

    Unoccupied more than 7 consecutive days in first 45 days of cover?

    Sum insured Required

    Residence 2 Address

    Address Code:

    Property use (tick appropriate option):

    Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune

    Construction and property type:

    Roof:

    Walls:

    Type of property

    Security:

    Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)

    Accidental Damage

    Sum Insured

    Subsidence & Landslip

    Current NCB/CFG:

    General information: Unoccupied more than 60 days p/a?

    Unoccupied more than 30 consecutive days during any year?

    Unoccupied more than 7 consecutive days in first 45 days of cover?

    Sum insured Required

    3. All Risk Section

    Unspecified All Risk / Blanket cover

    Under unspecified/blanket cover the item limit is 25% of the total sum insured for the section. (Example: If the sum insured is R100 000, then maximum claim per item would be R25 000)

    Specified Item

    Serial Number

    Insured Amount

    Vehicle sound equipment (not factory fitted), Cellular Phones, tablets, laptops, pedal cycles, sunglasses, stamp or coin collections, caravan contents, camping gear, golf clubs, firearms, GPS equipment, fishing gear etc must be insured under the All Risk Section, regardless of the value. Proof of ownership by means of invoice or valuation certificate must be made available on all claims

    1. Motor / Motorcycles

    Vehicle 1

    Type of Vehicle: (No carrying of commercial / trade goods)

    Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike

    Year of Manufacture

    Make and Model

    Engine Number

    Vin Number

    Registration Number

    Registered owner full names

    Registered owner id number

    Regular Driver Name

    Regular Driver ID no

    Regular Driver NCB / CFG

    Occupation of driver

    VEHICLESLicence year (mmyyyy) & type:

    Type

    Interest of Financial Institution

    Type of use

    PrivateBusiness

    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

    Rebuild / code 3 vehicle

    Performance modified

    Non- Factory fitted Accessories

    Item description

    Value

    Overnight Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Daytime Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Vehicle 2

    Type of Vehicle: (No carrying of commercial / trade goods)

    Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike

    Year of Manufacture

    Make and Model

    Engine Number

    Vin Number

    Registration Number

    Registered owner full names

    Registered owner id number

    Regular Driver Name

    Regular Driver ID no

    Regular Driver NCB / CFG

    Occupation of driver

    VEHICLESLicence year (mmyyyy) & type:

    Type

    Interest of Financial Institution

    Type of use

    PrivateBusiness

    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

    Rebuild / code 3 vehicle

    Performance modified

    Non- Factory fitted Accessories

    Item description

    Value

    Overnight Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Daytime Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    2. Motor Section Additional Vehicles

    Vehicle 3

    Type of Vehicle: (No carrying of commercial / trade goods)

    Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike

    Year of Manufacture

    Make and Model

    Engine Number

    Vin Number

    Registration Number

    Registered owner full names

    Registered owner id number

    Regular Driver Name

    Regular Driver ID no

    Regular Driver NCB / CFG

    Occupation of driver

    VEHICLESLicence year (mmyyyy) & type:

    Type

    Interest of Financial Institution

    Type of use

    PrivateBusiness

    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

    Rebuild / code 3 vehicle

    Performance modified

    Non- Factory fitted Accessories

    Item description

    Value

    Overnight Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Daytime Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Vehicle 4

    Type of Vehicle: (No carrying of commercial / trade goods)

    Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike

    Year of Manufacture

    Make and Model

    Engine Number

    Vin Number

    Registration Number

    Registered owner full names

    Registered owner id number

    Regular Driver Name

    Regular Driver ID no

    Regular Driver NCB / CFG

    Occupation of driver

    VEHICLESLicence year (mmyyyy) & type:

    Type

    Interest of Financial Institution

    Type of use

    PrivateBusiness

    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

    Rebuild / code 3 vehicle

    Performance modified

    Non- Factory fitted Accessories

    Item description

    Value

    Overnight Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Daytime Parking of vehicle

    Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gatesAccess controlled basementBehind locked gates uncovered

    3. Caravan/Trailer Section

    Caravan / Trailer 1

    CaravanTrailerOff road trailerMotorbike trailerBoat trailer

    Year of Manufacture

    Caravan / Trailer Make and Model

    Overnight Parking of vehicle

    Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Daytime Parking of vehicle

    Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Market value

    Caravan / Trailer 2

    CaravanTrailerOff road trailerMotorbike trailerBoat trailer

    Year of Manufacture

    Caravan / Trailer Make and Model

    Overnight Parking of vehicle

    Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Daytime Parking of vehicle

    Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

    Market value

    4.Pleasure/ Watercraft Section

    Type of vessel – Vessel 1

    Inflatable boat / rubber duckMotorboat inland <9mBow rider <9mCabin boat <9mMotorboat coastal <9mSail boat <9MWindsurfer

    Year of Manufacture

    Make and model of the vessel

    Serial / HIN number

    Engine/s – Type of engine

    InboardOutboard

    Number of Engine/s

    Make of engine/s

    Horse power

    Year of Manufacture

    Replacement value

    Serial NR

    Hull

    Replacement value

    Material of Hull

    Is the vessel self-built?

    YesNo

    Accessories to be noted

    Serial Number

    Replacement Value