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INSURED DETAILS

Title:

Surname *

Full names *

Tel: (w)

Cellphone *

Fax

Email *

Are you a South African citizen? *

SA ID Number *

Passport number *

Date of Birth *

Occupation *

Are you: *

Married
Single
Divorced
Widowed

Do you have a university degree of 4 years or more? *

What degree do you have? *

When did you obtain your degree? *

Where did you obtain your degree? *

Your physical address: *

Address Line 1

City

State / Province / Region

Postal Code

Postal address is the same as physical *

Postal address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Company name (if vehicle registered under company)

Company registration number: *

Are You Currently, or Have In The Past Been Insured? *

Name of Insurer: *

Policy Number *

Detailed 3 Years Claim History *

1. HOMEOWNERS INSURANCE (BUILDING)

This section caters for your dwelling and domestic outbuildings including landlord's fixtures and fittings, swimming pools including fixed filtration plant (not automatic pool cleaners), tennis courts, sauna and spa rooms and baths, borehole equipment, gates, walls, fences (excluding hedges) and driveways, paths and patios contracted of brick, concrete, pavers, asphalt or stone (not gravel). The sum insured should represent the current full rebuilding cost plus the cost of rubble removal, architect's fees and other incidental change required for rebuilding.

Do you need Homeowners Insurance? *

Sum insured required (Round off to Rands) *

Do you have a cottage, thatch lapa or a second dwelling on the property which is not of the same construction as the main residence? *

Please give full details *

Sum insured required (Round off to Rands) *

Describe the building construction: *

Age of building: *

Describe the roof construction: *

Is the construction approved by municipality?

Do you a have lapa/thatch? *

Specify *

Thatch
Lapa

Do you have a lightning mast for the thatched roof? *

Thatch treated: *

Size of lapa/thatch: *

Size of main dwelling: *

Lapa/thatch distance from main dwelling: *

Do you have a commune/staff quarters? *

Is this a holiday residence? *

Does the building have occupancy? *

Is there a swimming pool? *

Number of bedrooms: *

Who is the building occupied by? *

Describe the type of residence? *

Describe the situation of residence? *

Describe the wall construction *

Is the thatched roof thatch-safe? *

How long have you lived at this address

Years *

Months *

Occupation date *

Generally occupied 24hrs by insured? *

Will the property be unoccupied for more than 30 days? *

Is the property near a river or lake? *

Is the property near an open field? *

Do you have neighbours on all the borders of your property? *

Is your property bordered by:

Vacant land? *

Golf Course: *

Park? *

Stream/River/Lake? *

Small holding/farm? *

Squatter camp/informal settlement? *

Is the property occupied during the day? *

Will your home be unoccupied for more than 60 days in a year? *

Residence is (ie: flat, house, town house, cluster, etc) *

If flat, what floor are you on?

Residence is used for? *

Do you require Power Surge Cover? *

Sum Insured: *

Is your property financed? *

Who is it financed through? *

What is your finance number? *

What period is it financed for? *

When does finance period end? *

ADDITIONAL RISK INFORMATION

Domestic employed? *

Property used for business? *

Access controlled suburb? *

SECURITY DETAILS

Burglar alarm? *

All opening windows and doors covered by the alarm? *

Alarm has infra-red detectors? *

Alarm has a siren? *

Alarm linked to 24 hour armed response? *

Beams? *

Burglar bars on all opening windows? *

Perimeter wall? *

Electric fence in working order? *

Yes
No
No electric fence

Is your Electric fence linked to a 24 hour armed response company? *

Security gates on all opening doors leading outside? *

External doors (Including sliding doors) protected by proper grille/security gates? *

External sliding and glass doors fitted with additional frame mounted key-operated locking bolts? *

Electric gate or locked gates? *

Please specify *

Electric Gate
Locked Gates

24 Hour access control:? *

Full time security guards? *

Security firm

COVER DETAILS

Please supply detailed 3 years claims history *

No claim bonus: (number of years without claiming) *

Are you currently insured? *

With what Insurer? *

What is their policy number? *

2. HOUSEHOLD CONTENTS

Covers everything in your house against theft, fire, malicious or weather damages (storms, flooding, lightning). Contents insurance covers the financial cost of repairing or replacing your household personal possessions and furnishings, such as curtains, furniture, white goods, stereo, TV, computers and other electrical appliances, clothing, jewellery, sporting equipment and even toys.

Do you need Household Contents Insurance? *

Describe the type of residence? *

Describe the situation of residence? *

Describe the wall construction *

Describe the roof construction: *

Is thatched roof thatch-safe? *

Do you have a lightning mast? *

How long have you lived at this address? *

Is it unoccupied? *

Occupation date: *

Generally occupied 24hrs by insured? *

Will the property be unoccupied for more than 30 days? *

Is the property near a river or lake? *

Is the property near an open field? *

Is the property occupied during the day? *

By whom? *

Is this property a holiday home? *

Residence is (ie: flat, house, town house, cluster, etc) *

If flat, what floor are you on? *

Residence is used for: *

Sum insured:

Do you require Power Surge Cover? *

Sum insured: *

ADDITIONAL RISK INFORMATION

Domestic employed? *

Property used for business? *

Access controlled suburb? *

SECURITY DETAILS

Burglar alarm? *

All opening windows and doors covered by the alarm? *

Alarm has infra-red detectors? *

Alarm has a siren? *

Alarm linked to 24 hour armed response? *

Beam? *

Burglar bars on all opening windows? *

Perimeter wall? *

Electric fence perimeter? *

Electric fence in working order? *

Is your Electric fence linked to a 24 hour armed response company? *

Security gates on all opening doors leading outside? *

External doors (Including sliding doors) protected by proper grille/security gates? *

External sliding and glass doors fitted with additional frame mounted key-operated locking bolts? *

Electric gate or locked gates? *

Electric Gate
Locked Gate

24 Hour access control? *

Full time security guards? *

Please provide name of security firm *

COVER DETAILS

No claim bonus: (number of years without claiming) *

Are you currently insured? *

With what Insurer? *

What is their policy number? *

3. ALL RISKS COVER

Please specify any portable and/or high value items over R2,000 or cell phones, tablets, laptops, camera’s, scuba gear, sunglasses, heart rate monitors, artwork (paintings, sculptures, etc), stamp/coin/other collections, camping gear, jewellery, bicycles, generators, car radios/sound systems, firearms, etc.

Do you require Unspecified All Risks Cover:? *

What sum insured do you require: *

Specified portable possessions:

Are there any portable possessions that you would like to insure?

Details of items being specified: *

Details of items being specified: (copy)

Details of items being specified: (copy) (copy)

Details of items being specified: (copy) (copy) (copy)

Details of items being specified: (copy) (copy) (copy) (copy)

Do you need to add more items?

Details of items being specified:

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IME / Serial numbers: *

IME / Serial numbers: (copy)

IME / Serial numbers: (copy) (copy)

IME / Serial numbers: (copy) (copy) (copy)

IME / Serial numbers: (copy) (copy) (copy) (copy)

Do you need to add more serial numbers?

IME / Serial numbers: (copy) (copy) (copy) (copy) (copy)

IME / Serial numbers: (copy) (copy) (copy) (copy) (copy) (copy)

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Value / Sum insured: *

Value / Sum insured: (copy)

Value / Sum insured: (copy) (copy)

Value / Sum insured: (copy) (copy) (copy)

Value / Sum insured: (copy) (copy) (copy) (copy)

Do you need to add more values?

Value / Sum insured:

Value / Sum insured: (copy)

Value / Sum insured: (copy) (copy)

Value / Sum insured: (copy) (copy) (copy)

Value / Sum insured: (copy) (copy) (copy) (copy)

4. MOTOR VEHICLE OR MOTORCYCLE

You need to have motor insurance before you can drive your vehicle in a public place. It protects you, your vehicle and other motorists against liability in case there is an accident. It provides financial compensation to cover any injuries caused to people or their property. You can add on vehicle car hire under this policy.

There are various value-added products that can be added onto this insurance. If the vehicle is financed, then credit shortfall / top up/gap cover should be selected. Credit shortfall insurance, or gap insurance, covers the difference between the amount your vehicle is insured for and how much you still owe on it to the finance house. There are also these covers available: scrat and dent, interior damage, tyre warranty, excess protector, extended motor warranty, motor service and maintenance plan.

Motorcycle/motorbike insurance
Covers you for accident damage, theft and hi-jacking, and for your liability to other parties following a motorbike accident. There are various value-added products that can be added onto this insurance. If the motorcycle is financed, then credit shortfall / top up/gap cover should be selected. Credit shortfall insurance, or gap insurance, covers the difference between the amount your motorcycle is insured for and how much you still owe on it to the finance house

Do you need motor vehicle/motocycle insurance?

Which vehicle do you need insurance for? *

Motorcycle
Motor Vehicle

Make: *

Model: *

Year: *

Mead & McGrouther Code (Auto Dealers Digest): *

Registration number: *

Engine Number: *

VIN number: *

Colour of the vehicle: *

Type of vehicle: *

Engine type: *

Is the vehicle subject to a credit (hire purchase) or similar agreement? *

Name of the institution: *

Finance agreement number: *

Type of agreement: *

Amount owed: *

Period of agreement: *

End date of agreement: *

Has the vehicle been: modified in any way after leaving the manufacturer? *

Specify non-standard accessories: *

Re-built or previously been written off by an insurance company? *

Sum insured: *

Do you want to insure your vehicle for: Market Value or Retail Value *

Market Value
Retail Value

Full name & surname of the main driver: *

ID number of main driver *

When did driver obtain drivers licence card?

What licence code does driver have? *

Registered owner of vehicle: *

Will there be any other drivers? *

Full names & surname of the other driver: *

ID number of other driver: *

When did driver obtain drivers licence card? *

What licence code does driver have? *

Has your driver's license or that of any person who you know will drive the vehicle, ever been endorsed, suspended or cancelled? *

Please give details? *

Previously insured? *

Who were your previous insurers? *

What is your policy number? *

How long have you been insured with them? *

3 Years claims history: (number of claims and value) *

COVER DETAILS

Class of use: *

Business
Personal
Both

Social, domestic, pleasure and business or professional but EXCLUDING commercial Use traveling, driving instruction for reward or for use in connection therewith.

Cover type: *

Comprehensive
Third party
Third party fire and theft

No claim bonus: *

VEHICLE SECURITY

Residential address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Postal is the same as residential *

Postal address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Where will vehicle be kept during the day? *

Where is the vehicle kept overnight? *

Behind locked gate
In garage
On the street

Any extras (bull bars, tow bars, canopy, sound system, mags, etc)? *

Description of vehicle extras *

Description of vehicle extras (copy)

Data Dot? *

Alarm? *

Please provide a brief description of type of alarm *

Gear lock? *

Immobiliser? *

Please provide a brief description of type of alarm *

Tracking device? *

Type of tracking device? *

Who is your tracking device with? *

Is the device/s factory fitted? *

Is the device/s in working condition? *

Please attach copies of the installation certificates for the gear lock, immobiliser or tracking device

File Upload

Click or drag a file to this area to upload.

Do you require Car Hire cover? *

For what period/duration? *

30 Day
60 Days
90 Days

Do you require Top Up cover? *

Please advise how much cover is required: *

Do you require Credit Life cover? *

Please advise outstanding loan amount: *

Value of extras *

Value of extras (copy)

Value of extras (copy) (copy)

Value of extras(copy) (copy) (copy)

Do you require Tyre Warrantee cover? *

Please advise the make and value of each tyre

Tyre Make(s) *

Do you require Scratch and Dent cover? *

Would you like an excess buster or a voluntary excess? *

Excess buster
Voluntary excess

How much voluntary excess would you like? *

Tyre Value(s) *

5. CARAVAN AND TRAILER INSURANCE (PRIVATE USE ONLY)

NB: Caravan contents should be insured under the All-Risks section as separate specified item but covering the total caravan contents except those articles which are supplied as part of a new caravan.

Do you need private caravan and trailer insurance? *

Make *

Sum insured: *

Registration number: *

Model *

Year of manufacture: *

Full name of registered owner: *

6. BOATS UP TO R 70 000

(IE: Jet Ski’s, Small Boats for personal use) Includes onboard motors, machinery, equipment and standard fittings, such as the hull and accessories which are normally included when purchasing a watercraft.

Do you require boat insurance? *

Please provide details for the HULL

Make and/or class of manufacture : *

Please provide details for the ENGINE

Year of Manufacture : *

Make & Model *

Year of Manufacture *

Horsepower *

Sum Insured:

Hull: *

Engine: *

Please tick the applicable: *

Motorboat with a maximum speed of 40kph
Motorboat with a maximum speed between 40-80kph
Motorboat exceeding speed of 80kph

7. PERSONAL LIABILITY INSURANCE AND EXTENDED LIABILITY

This section provides cover for claims for accidental injury or damage caused by you or members of your immediate family normally resident with you and for which you are legally liable. Please indicate the limit of indemnity you require. (Should you wish to insure the contents of a second house please complete another proposal).

Do you need Personal Liability Insurance and Extended Liability? *

Tick relevant box for which sum insured your require: *

R1 000 000
R3 000 000
Other

Other Amount *

8. RIOT INSURANCE

This cover is automatically included in respect of the property detailed on this proposal.

9. GENERAL

Has any insurer ever cancelled or refused to insure or continue insurance or imposed restrictions for any risks you now wish to insure? *

Please provide details: *

10. PLEASE SIGN THE FOLLOWING DECLARATION

Is there any other material fact that may influence the risk for which you have applied for insurance? *

Please provide full particulars: *

I warrant that the information in this proposal to be true and correct and complete in every respect and that I have not withheld or changed any material information.

Signed (please print your name here): *

SIGNATURE: *

Dated: *

I acknowledge that the sharing of claims information and underwriting information (including credit information) by insurers is essential to enable the insurance industry to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims, in the public interest and with a view to limiting premiums. On behalf of myself and on behalf of any person I represent herein, I hereby waive any right to privacy in any insurance information provided by me or on my behalf in respect of any insurance policy or claim made or lodged by me and I consent to such information being disclosed to any other insurance company or its agent. I also acknowledge that the information provided by me may be verified against other legitimate sources or databases. I also waive any rights of privacy and consent to the disclosure of any information relevant to any insurance policy or claim concerning myself.

Signed (please print your name here): *

SIGNATURE: *

Dated: *

Get Covered In Minutes.

INSURED DETAILS

1. HOMEOWNERS INSURANCE (BUILDING)

2. HOUSEHOLD CONTENTS

3. ALL RISKS COVER

4. MOTOR VEHICLE OR MOTORCYCLE

5. CARAVAN AND TRAILER INSURANCE (PRIVATE USE ONLY)

6. BOATS UP TO R 70 000

7. PERSONAL LIABILITY INSURANCE AND EXTENDED LIABILITY

8. RIOT INSURANCE

9. GENERAL

10. PLEASE SIGN THE FOLLOWING DECLARATION

Have Questions? Ask A Specialist

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Legislation Requirements