UMA MOTOR ONLY PROPOSAL FORM

Transcription

1 UMA MOTOR ONLY PROPOSAL FORM Naam van kliënt Name of client Posadres Postal INLIGTING - NUWE KLIËNTE INFORMATION - NEW CLIENTS Poskode Postal Code Telefoon Nr. Telephone No. E-pos adres address Risiko Adres Risk Address Beroep Occupation Faks Nr. Fax No. ID No ID Nr Selfoon Cellphone Taal Language Is u nou of was u ooit verseker? Indien wel, meld naam van die versekeraar en polisnommer. Are you now or have you ever been insured? if so, state name of insurer and policy number. Nr / No 2. Het enige versekeraar ooit/has any insurer ever: a. U aansoek geweier? Declined your proposal? b. c. U polis gekanselleer of geweier om dit te hernu Cancelled or refuse to renew your policy? Spesiale voorwaardes of verhoogde premies of bybetalings ingestel Imposed special conditions or increased premiums or excesses? Indien bevestigend, verstrek volledige besonderhede/if affirmative, give full details Aanvangsdatum van dekking Inception date of cover Pensionares Pensioner Naam van Agent / Makelaar Name of Agent / Broker Page 1

2 LETTER OF APPOINTMENT Date: We,, (hereinafter the Client ), hereby appoint UMA Insurance Brokers (hereinafter UMA ) as our Insurance intermediary with immediate effect, and please co-operate fully with them in providing any information they may request. We, the Client, confirm that we have been made aware of and hereby agree to the following:- Our duties of Disclosure and of Good Faith, and in particular our obligation to disclose to insurers any material circumstance which may in any way affect the risk or the underwriters decision to insure it, and at what price. 2. Our duty to notify circumstances that could give rise to a claim as soon as possible, and certainly within any time period stipulated in the relevant Policy Although UMA only utilize reputable insurers for the placement of business, they cannot accept responsibility for the future solvency of these insurers nor for their ability or otherwise to pay claims. UMA currently have Professional Indemnity and Fidelity Guarantee insurance coverage in place. Notwithstanding this, UMA hereby limit there Liability for any loss or damage that the Client may suffer arising directly or indirectly from UMA s performance or non-performance whether arising out of negligence or any other cause, to a maximum amount of R50 Million in all, and furthermore UMA will not under any circumstances be liable to the Client for any indirect, consequential or economic loss nor for punitive damages. 5. The necessity for us to pay the premium upon presentation of invoices, and that failure to do so may invalidate our insurance coverage. 6. UMA undertake to act at all times in accordance with the SAFSIA Code of Conduct as well as in terms of the FAIS Act No.37 of 2002, which means that UMA will conduct business in good faith and with integrity, and will provide the Client with appropriate short-term insurance related advice, and intermediary services relating to the placement of the Clients insurance coverage with the selected insurer, and assistance with the annual renewal of insurance contracts, and advice and services relating to Claims. We, the Client, understand the content of this Letter of Appointment and we hereby accept these terms and conditions as the basis of the appointment of UMA as our insurance intermediary as confirmed by our signature hereunder. Signed at on this day of 2 For and on behalf of (the Client) CLIENT SIGNATURE WITNESS Who warrants that he/she is duly authorized to act on behalf of the Client Signed at on this day of 2 INTERMEDIARY SIGNATURE WITNESS Who warrants that he/she is duly authorized to act on behalf of UMA Page 2

3 DECLARATION (You must complete and sign this section) Have you or any member of your firm had any application for insurance been declined or insurance cancelled, or renewal refused or not invited, or had special conditions imposed? Y/N. 2. Have you or any member of your firm been involved in any civil or criminal litigation in the past 3 years? Y/N 3. Have you or any member of your firm ever made an agreement with creditors regarding debt, or been sequestrated, or been declared insolvent? Y/N.. 4. Have you or any member of your firm had any civil judgements recorded against you? Y/N. If yes, provide full details regarding every individual judgement 5. Have you or any member of your firm had any civil judgements recorded against you? Y/N.... If yes, provide full details regarding every individual judgement 6. Do you keep a complete set of books showing a true and accurate record of business transacted? Y/N. 7. Give details of All losses suffered in the past 3 years (whether insured or not) Type of loss (Fire, Motor, Accident, Burglary ect..) Year Loss Amount I/We declare that all particulars and answers in this proposal and application are true and complete in every respect, and that no material fact has been suppressed or withheld. I/We further declare that if these statements and particulars are the writing of any person other than myself/ourselves, such person shall be deemed to have been my/our Agent for the purpose. I/We agree that this declaration and the details given shall be the basis of the contract between myself/ourselves and the Insurance Company (referred to as the company). I/We further agree to accept a policy subject to the usual conditions prescribed by the Company and endorsed on their policy, and to pay premium there under. I/We undertake to exercise all ordinary and reasonable precautions for the safety of the property for which insurance is proposed... Capacity Page 3

4 DEBIET ORDER MAGTIGING / DEBIT ORDER AUTHORITY PREMIE BETAALWYSE / PREMIUM PAYMENT METHOD MAANDELIKSE DEBIET ORDER / MONTHLY DEBIT ORDER REKENING TIPE / ACCOUNT TYPE SPAAR \ SAVINGS TRANSMISSIE \ TRANSMISSION TJEK \ CHEQUE NAAM VAN REKENING HOUER / NAME OF ACCOUNT HOLDER NAAM VAN BANK / NAME OF BANK TAK & TAK KODE / BRANCH & BRANCH CODE REKENING NOMMER / ACCOUNT NUMBER DEBIET ORDER DATUM / DEBIT ORDER DATE GETEKEN DEUR REKENING HOUER / SIGNED BY ACCOUNT HOLDER : I HEREBY GIVE UMA UNDERWRITING CONSULTANTS PERMISSION TO DEDUCT MY INSURANCE PREMIUM MONTHLY FROM MY BANK ACCOUNT. MOTOR MAAK EN MODEL MAKE AND MODEL JAAR YEAR TIPE DEKKING TYPE OF COVER WAARDE VALUE PREMIE PREMIUM REG NO ONDERSTEL VIN NO SEKURITEITS STELSEL SECURITY SYSTEM ENJ NO ENG NO LISENSIE EERSTE UITREIKING DATUM LICENSE FIRST ISSUE DATE GEB NCB OPSIONELE DEKKING / OPTIONAL COVER Koste / Cost Motor Huur / Car Hire LDV Huur / LDV Hire Afkoop van Bybetaling / Excess Waiver Assist / Bystand Perlk / Limit R Krediettekort / Credit shortfall Perlk / Limit R Motor Radio / Motor Radio Beskrywing / 10% rate Voertuig op enige manier gemodifiseer. Vehicle in anyway modified? Voertuig 'n Kode 3 / Vehicle code 3? Yes R Page 4

5 Voertuig Sekuriteitsvereistes / Vehicle Security Requirements R 0 - R VSS of SAIA Immobiliseerder vlak 3 / VSS or SAIA Approved Immobilizer level 3 R R VSS of SAIA vlak 4 Immobiliseerder / VSS or SAIA level 4 Immobilizer R VSS of SAIA Voertuigopsporingstelsel / VSS or SAIS Vehicle Tracking Device Nie-nakoming van enige van bogenoemde vereistes ten opsigte van Diefstal en of Kaping sal geen dekking tot gevolg hê. Non compliance of the above security requirements will result in No Teft and Hijack cover. EERSTE BEDRAE BETAALBAAR / EXCESS STRUCTURE Basiese Bybetalings / Basic Excess: 7.5% van eis Minimum R / 7.5% of claim Minimum R Windskerm Bybetaling / Windscreen Excess: 20% van eis Minimum R / 20% van claim Minimum R Radio & Toerusting Bybetaling / Audio & Equipment Excess : 10% van eis Minimum R 500 / 10% of excess Minimum R Verlies van Sleutels Bybetaling / Loss of Keys Excess: 10% van eis Minimum R / 10% of claim Minimum R Diefstal & Kaping Bybetaling / Theft & Hijack Excess: 10% van eis Minimum R / 10% of claim Minimum R Tweede Eis in 1 Jaar / Second Claim in 1 year: Addisionele R / Addisional R Eis binne 6 Maande van Aanvang / Claim within 6 months of Inception: Addisionele 5% van eis Minimum R / Addisional 5% of claim Minimum R Derde Party Bybetaling indien geen eie skade nie / Third Party Claim if no own damage: R Onder 25 & Lisensie korter as 5 jaar / Under 25 & license not longer than 5 years: 5% van eis Minimum R / 5% of claim Minimum R Hiermee verklaar ek, die versekerde dat my voertuig aan die sekuriteits vereistes soos bo genoem voldoen en indien my voertuig nie aan die vereistes voldoen nie dat die nodige sekuriteits stelsel binne 7 dae van aanvangsdatum geinstalleer sal word. Hiermee verstaan ek ook dat na die 7dae daar geen Diefstal / Kaping dekking toegestaan sal word nie indien die bewys van installasie gelewer kan word. With this signature I the insured declare that my vehicle comply with the above security requirements. If not, I declare that the necessary security system will be installed within 7days of inception of policy. I understand after 7days Theft / Hijack cover will only be given if proof of installation can be provided. Handtekening / Signature Page 5