I hereby authorise Echelon Private Client Solutions (Pty) Ltd, on behalf of Santam Ltd, to debit my bank account noted above

Transcription

1 COMBINED POPOSAL BOKE INFOMATION Broker: Broker Fee: % Quote Number: Quote Amount: CLIENT INFOMATION Full Name of Policy Holder: I.D/Company egistration Number: VAT Number: Gender: Male Occupation: Contact Number: Home Contact Number: Work Marital Status: Contact Number: Cell Contact Number: Fax E- mail Address: Address: esidential Address: Postal DEBIT ODE AUTHOITY POLICY DETAILS Inception Date: Payment Frequency: Monthly Annually BANK DETAILS Bank: Branch Name: Branch Code: Account Number: Account Holder: Type of Account: Current Transmission Savings Authorisation by Account Holder I hereby authorise Echelon Private Client Solutions (Pty) Ltd, on behalf of Santam Ltd, to debit my bank account noted above Signature of Account Holder: Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.:

2 COMBINED POPOSAL ISK INFOMATION - MOTO VEHICLE 1 VEHICLE 2 Make: Model: Year of Manufacture: egistration Number: Details and Value of Accessories: Details and Value of Audio Equipment (If not Factory Fitted): etail Value of Vehicle: Transmission: Manual Manual Automatic Automatic Engine Number: Vin Number: egistered Owner: Overnight Storage: Locked Garage Locked Garage On Street On Street Vehicle Located at (Address): Current Vehicle Security: Tracking Device Details: Car- Hire: Standard Standard Executive (Group F - Extra 45p/m) SUV (Group K Extra 90p/m) Executive (Group F - Extra 45p/m) SUV (Group K - Extra 90p/m) Name of Main Driver: Main Driver I.D./Age: Main Driver Gender: Male Male Main Driver Marital Status: Main Driver Occupation: Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.:

3 COMBINED POPOSAL VEHICLE 1 VEHICLE 2 Use of Vehicle: Business Business CFG of Main Driver: (Copy of schedule to be Provided) Private Both Private Both Bank Interests to be ted: 3 Year New for Old: Yes Yes Excess Waiver (up to ): Yes Yes Excess Waiver (up to ): Yes Yes Credit Shortfall: Yes Yes Extended 4x4: Yes Yes Motor Personal Accident (MPA): Yes Yes MPA Passenger Extension: Yes Yes MPA Maximum Indemnity Limit: 250, , ,000 1,000,000 ISK INFOMATION MOTO CYCLES MOTOCYCLE 1 MOTOCYCLE 2 Make: Model: Year of Manufacture: etail Value: egistration Number: Category: Off- road Bike Off- road Bike Quad Superbike oadbike/tourer Scooter Quad Superbike oadbike/tourer Scooter Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.:

4 COMBINED POPOSAL MOTOCYCLE 1 MOTOCYCLE 2 Engine Number: Frame Number: egistered Owner: Name of Main Driver: Main Driver I.D./Age: Main Driver Gender: Male Male Overnight Storage: Locked Garage Locked Garage Vehicle Located at (Address): Current Vehicle Security: ISK INFOMATION PEMISES 1 PEMISES 2 BUILDINGS/CONTENTS isk Address: Type of esidence: House House Apartment Townhouse Cluster Farm Holiday House Other Apartment Townhouse Cluster Farm Holiday House Other Construction - oof: Standard Standard n- std Thatch n- std Thatch Construction - Walls: Standard Standard n- standard n- standard Subsidence & Landslip: Yes Yes (Complete Questionnaire) (Complete Questionnaire) Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.:

5 COMBINED POPOSAL PEMISES 1 PEMISES 2 Occupied by: Owner Owner Tenant Tenant Occupied during the day: Yes Yes Security: Burglar Bars on Burglar Bars on Opening Windows Opening Windows Security Gates on External Doors Security Gates on External Doors 24 Hour Alarm linked 24 Hour Alarm linked to Armed esponse to Armed esponse Electric Fence linked to Armed esponse Electric Fence linked to Armed esponse esponse Co. Name : Patrolled by Security Guards Secure Estate Unoccupied Longer than 60 Days Patrolled by Security Guards Secure Estate Unoccupied Longer than 60 Days CFG : (Copy of schedule to be provided) Interests to be noted: Maximum Indemnity/Buildings Main Building: Main Building: (Please ensure all outbuildings are included. Premium and claims settlement will be based on the value of all buildings on the premises) Outbuildings: Outbuildings: Maximum Indemnity/: at Premises: at Premises: Jewellery/Watches at Premises: Items in Bank Vault: Jewellery/Watches at Premises: Items in Bank Vault: isk Assessment equired: Building Building Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.:

6 COMBINED POPOSAL PEMISES 1 PEMISES 2 Excess Waiver: Building Building Extended Business : Yes Yes ISK INFOMATION - PESONAL ALL ISKS Unspecified Personal All isks: (Limited to 20% of Maximum Indemnity for ) Specified Items and Values: DESCIPTION SEIAL NO. IN BANK VAULT (Y/N) VALUE ISK INFOMATION AICAFT Please complete supplementary aircraft proposal. ISK INFOMATION - WATECAFT Type of Craft: igid Semi- igid Full Inflatable Semi- Inflatable Jetski/Wetbike Construction of Hull: Details of Motor/s: Storage when not in Use: Locked Garage Driveway Use of Vessel: Inland Only Inland and Coastal Coastal and Surf Launch Name of Pilot: Date of Birth of Pilot: Experience of Pilot (Years): Date of Skipper's Licence: Sum Insured: Hull: Details : Motors Details: Accessories Details: Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.:

7 COMBINED POPOSAL ISK INFOMATION CAAVANS/TAILES Make and Model: Year of Manufacture: Sum Insured: ISK INFOMATION - PESONAL ACCIDENT Full Name: I.D Number: Maximum Indemnity Limit: 100, , , ,000 1,000,000 1,500,000 2,000,000 Domestic Employee Extension: Yes ISK INFOMATION ADDITIONAL BENEFITS Identity Theft Yes etrenchment Benefit: Yes oadside/home Assistance: Yes LOSS HISTOY & GENEAL INFOMATION Does the Policyholder/Client/Main Driver or any other driver, suffer from defective vision, hearing or from any physical or mental infirmity? Yes Please provide details: Is the Policyholder/Client/ Main Driver or other driver's licence currently endorsed, or has it previously been endorsed? Yes Please provide details: Has the Policyholder/Client/Main Driver suffered any losses, insured or otherwise, in the past 5 years? Yes DETAILS OF INCIDENT YEA AMOUNT CLAIMED Has any insurer ever refused any proposal of yours, cancelled any policy (or section thereof), refused to renew or imposed any special conditions on any policy (or section thereof) Yes If yes, please provide full details: Please provide details of your current insurance policy: WAANTY I hereby warrant that the above particulars and statements are true and complete and contain all information known to me affecting the risks to be insured and that this and any other statement made by me or on my behalf for the purpose of the proposed insurance shall be the basis of and incorporated in the contract between me and Santam Limited herein represented by Echelon Private Client Solutions (Pty) Ltd t/a Echelon and shall be promissory. I agree to accept the insurance on the terms and conditions set forth in the policy. Date Signature of Policy Holder Johannesburg Telephone.: /5/6/7/8 Fax.: Cape Town Telephone.: Fax.: