ACCENSURE INSURANCE BROKERS PTY (LTD)
Accensure House, 81 on Vasco Boulevard, Goodwood, 7460 P. O. Box 12061, Goodwood 7463 Vat No. 4060207786
Tel: (021) 592 0122 Fax: (021) 592 0138 Email: info@accensure.co.za Reg No. 2003/017482/07 Fais No. 14215
PROPOSAL & QUESTIONNAIRE
*PLEASE PRINT ALL ANSWERS OR TICK APPLICABLE BOX.
TITLE / FIRST NAME & SURNAME: ______________________________________________________________________________________
IDENTITY NO: _____________________________________________ DATE OF BIRTH: __________________________________________
OCCUPATION: ______________________________________________________________________________________________________
RESIDENTIAL ADDRESS: _____________________________________________________________________________________________
__________________________________________________________________________POSTAL CODE: ___________________________
POSTAL ADDRESS: __________________________________________________________________________________________________
__________________________________________________________________________ POSTAL CODE: ___________________________
TEL NO (H) _____________________________ ________ (W) ________________________________ ( FAX) __________________________
CELL NO: _______________________________________________ E-MAIL: ____________________________________________________
POLICY INCEPTION DATE: _______/ _______/ ___________BROKER DETAILS: ________________________________________________
BUILDINGS
DO YOU WANT TO INSURE THE BUILDING? YES NO
WHAT IS THE ESTIMATE REPLACEMENT VALUE OF YOUR BUILDING? R______________________________
HOLIDAY DWELLING? YES NO ; THATCHED YES NO ; UNOCCUPIED YES NO ; STANDARD NON-STANDARD
CONTENTS
DO YOU WANT TO INSURE YOUR HOUSE CONTENTS? YES NO
WHAT IS THE ESTIMATE REPLACEMENT VALUE OF YOUR ENTIRE CONTENTS? R_____________________________CFG_______
PLEASE SUPPLY DETAILS OF THE SECURITY AT YOUR HOME:
DO YOU LIVE IN A HOUSE YES NO ; FLAT YES NO ; HOSTEL YES NO ; OTHER YES NO
IF OTHER PLEASE SPECIFY YES NO
ALARM LINKED TO 24HOUR ARMED RESPONSE? YES NO
BURGLAR BARS ON ALL OPENING WINDOWS? YES NO
SECURITY GATES ON ALL EXITS, SLIDING & PATIO DOORS? YES NO
VACANT AREA IN IMMEDIATE SURROUNDINGS? YES NO
STANDARD ROOF AND WALL CONSTRUCTION? YES NO
IS PREMISES OCCUPIED DURING THE DAY? YES NO
IS IT IN AN ESTABLISHED AREA? YES NO
ARE THERE ANY NEW BUILDINGS UNDER CONSTRUCTION IN THE AREA? YES NO
INFORMAL SETTLEMENT IN SURROUNDING AREA WITHIN 2 KM? YES NO
ALL RISKS
DO YOU WISH TO INSURE ANY GENERAL UNSPECIFIED ITEMS E.G CLOTHING AND WEARING APPAREL WHILST HAVING THEM AWAY FROM
YOUR PREMISES? (ARTICLES ARE LIMITED TO R1000 PER ITEM) YES NO R________________________
ANY ITEM YOU WANT TO SPECIFY E.G CAR RADIOS, CELL PHONES, ETC? YES NO IF YES, PLEASE LIST THEM
MAKE/MODEL_________________________________________ R_____________________SERIAL NO_______________________________
MAKE/MODEL_________________________________________R______________________SERIAL NO_______________________________
MAKE/MODEL_________________________________________R______________________SERIAL NO_______________________________
MAKE/MODEL_________________________________________R______________________SERIAL NO_______________________________
KINDLY NOTE: WE NEED A VALUATION CERTIFICATE FOR ANY JEWELERY ITEMS IN EXCESS OF R10000.
CAR RADIO/SOUND EQUIPMENT & CELL PHONES MUST BE SPECIFIED UNDER THE ALL RISK SECTION IN ORDER TO ENJOY COVER.
MOTOR
DO YOU WISH TO INSURE YOUR MOTOR VEHICLES, MOTOR CYCLES, TRAILER AND CARAVANS? YES NO
MAGWHEELS TO BE SPECIFIED UNDER THE ALL RISK SECTION
MAKE: (E.G. TOYOTA) 1: _______________________________ 2: ______________________________ 3: ____________________________
MODEL: (E.G. RSI 16V) _______________________________ ______________________________ _____________________________
YEAR MANUFACTURED: _______________________________ ______________________________ ____________________________
REGISTRATION NO: _______________________________ ______________________________ ____________________________
INSURED VALUE: _______________________________ ______________________________ ____________________________
COVER: (COMP / TPF&T _______________________________ ______________________________ ____________________________
ENGINE NUMBER: ________________________________ ______________________________ ____________________________
CHASSIS NUMBER: ________________________________ ______________________________ ____________________________
PRIVATE/BUSINESS: ________________________________ ______________________________ ____________________________
REGISTERED OWNER: ________________________________ ______________________________ ____________________________
CLAIMS FREE GROUP: ________________________________ ______________________________ ____________________________
DRIVER/S DETAILS
(FULL NAME)
REGULAR DRIVER: _______________________________ ______________________________ ____________________________
OCC OF DRIVER: _______________________________ ______________________________ ____________________________
ID NUMBER OF DRIVER: _______________________________ ______________________________ ____________________________
HAVE YOU BEEN AUTHORISED BY THE OWNER TO INSURE THE VEHICLE? YES NO
WILL THE VEHICLE BE DRIVEN BY ANY PERSON WHO:-
HAS HELD A LICENCE FOR LESS THAN 2 YEARS? YES NO
(DATE OF FIRST ISSUE OF LICENCE)
IF YES, PLEASE PROVIDE FULL DETAILS: ________________________________________________________________
IS UNDER 25 YEARS OF AGE? YES NO
HAS DEFECTIVE VISION, HEARING OR PHYSICAL DEFECTS? YES NO
BEEN CONVICTED OF ANY DRIVING OFFENCES YES NO
(IN THE PAST FIVE YEARS)
IF YES, PLEASE PROVIDE FULL DETAILS: ________________________________________________________________
HAS THE VEHICLE BEEN MODIFIED? YES NO
IS THE VEHICLE A CODE 3 TYPE( BUILT UP) YES NO
IMPORTED VEHICLE? YES NO
PLEASE PROVIDE SECURITY AND OVERNIGHT PARKING OF VEHICLE/S:
VEHICLE 1. ALARM YES NO ; VESA APPROVED IMMOBILISER YES NO ; GEARLOCK YES NO ;
TRACKING DEVICE YES NO ;
OVERNIGHT PARKING: LOCKED GARAGE YES NO ; LOCKED GATES YES NO ; CARPORT YES NO ;
ACCESS CONTROLLED COMPLEX YES NO .
VEHICLE 2. ALARM YES NO ; VESA APPROVED IMMOBILISER YES NO ; GEARLOCK YES NO ;
TRACKING DEVICE YES NO ;
OVERNIGHT PARKING: LOCKED GARAGE YES NO ; LOCKED GATES YES NO ; CARPORT YES NO ;
ACCESS CONTROLLED COMPLEX YES NO .
VEHICLE 3. ALARM YES NO ; VESA APPROVED IMMOBILISER YES NO ; GEARLOCK YES NO ;
TRACKING DEVICE YES NO ;
OVERNIGHT PARKING: LOCKED GARAGE YES NO ; LOCKED GATES YES NO ; CARPORT YES NO ;
ACCESS CONTROLLED COMPLEX YES NO .
PERSONAL LIABILITY
PERSONAL LIABILITY INSURANCE WILL BE INCLUDED IN YOUR POLICY TO A LIMIT OF R2 500 000 AT A PREMIUM OF R3.00 PER MONTH.
PERSONAL ACCIDENT
DETAILS OF PROPOSER: 1: ______________________________________ 2: _____________________________________
DATE OF BIRTH: ________________________________________ _______________________________________
AMOUNT: R_______________________________________ R______________________________________
GENERAL
PLEASE PROVIDE THE FOLLOWING INFORMATION WHICH IS REQUIRED BY THE INSURANCE COMPANY:
IF YES, PLEASE STATE NAME AND ACCOUNT NUMBER OF FINANCE HOUSE: ________________________________________
HAVE YOU PREVOIUSLY BEEN INSURED: YES NO ;
IF YES, WITH WHOM, FOR HOW LONG AND PLEASE PROVIDE POLICY NUMBER________________________________________________
WILL THIS POLICY REPLACE YOUR PREVIOUS INSURANCE? YES NO
HAS ANY INSURER EVER CANCELLED YOUR INSURANCE? YES NO
HAS ANY NSURER CANCELLED YOUR POLICY DUE TO NON PAYMENT OF PREMIUM? YES NO
HAS ANY INSURER PLACED ANY SPECIAL CONDITIONS ON YOUR POLICY? YES NO
HAS YOUR LICENCE EVER BEEN ENDORSED? YES NO
HAVE YOU EVER BEEN CONVICTED OF A DRIVING OFFENCE? YES NO
HAVE YOU EVER BEEN DECLARED INSOLVENT? YES
NO
IF YES TO ANY OF THE ABOVE, PLEASE TELL US WHY? ____________________________________________________________________
_____________________________________________________________________________________________________________________
HAS THE AVERAGE CLAUSE BEEN EXPLAINED TO YOU? YES NO
(AVERAGE CLAUSE IT IS IMPERATIVE THAT YOUR SUMS INSURED OFALL VEHICLES, CONTENTS OR BUILDINGS ETC. ARE ADEQUATELY
INSURED, AS AVERAGE WILL APPLY IF THE SUMS INSURED ARE UNDERINSURED.
ARE YOU ENTITLED TO A NO CLAIMS BONUS? YES NO
IF YES, PLEASE PROVIDE PROOF OF CLAIMS.
CLAIMS HISTORY
PLEASE SUPPLY CLAIMS/ACCIDENTS INFORMATION WHETHER INSURED OR NOT FOR THE PAST 3 YEARS
TYPE OF LOSS YEA DATE AMOUNT INSURER
PERMISSION TO CHECK FOR PREVIOUS CLAIMS YES
NO
PERMISSION TO CHECK IF DRIVERS LICENCE IS VALID YES NO
SIGNATURE: DATE: _________
PLEASE NOTE THAT COVER IN TERMS OF THIS POLICY WILL ONLY COMMENCE AFTER APPROVAL BY
ACCENSURE INSURANCE BROKERS (PTY) LTD
DEBIT ORDER AUTHORITY
ACCOUNT HOLDER: ______________________________________________________________________
BANK NAME: ______________________________ BRANCH: _________________________
BRANCH CODE: _________________________ ACCOUNT NUMBER: _________________________
ACCOUNT TYPE: (SAVINGS, CHEQUE, TRANSMISSION) _________________________
MONTHLY PAYMENT DATE: 1ST - 3rd - 5th - 7TH - 10th - 15TH (CIRCLE APPROPRIATE DATE)
I/WE THE UNDERSIGNED, HEREBY AUTHORISE ACCENSURE INSURANCE BROKERS (PTY) LTD. TO ARRANGE
WITH MY/OUR BUILDING SOCIETY, TO COLLECT PREMIUMS PAYABLE IN TERMS OF MY/OUR INSURANCE
POLICY, FROM MY/OUR BANKING ACCOUNT IN ACCORDANCE WITH A DEBIT ORDER SYSTEM.
_____________________________________ _______________________
SIGNATURE OF ACCOUNT HOLDER DATE
ADDITIONAL NOTES
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