Commercial Application form

Transcription

1 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Commercial Application form INSUANCE BOKE Broker Name : Contact number: Agency Code: CLIENT DETAILS Business Name: egistration Number/ID Number: isk Address: Contact Person: Contact Number: Period of Insurance: From ISK DETAILS Business Description(Full Details): isk Address: Capacity: to Code: Occupation of Premises: Building Construction: Hazardous Process: Estimated Annual Turnover: Estimated Annual Carry: PEVIOUS INSUANCE 1. Has any insurer ever declined a proposal of yours, cancelled any policy (or any section thereof) of yours, imposed any special conditions, refused to renew any policy (or any section thereof) of yours, or refused to continue with any insurance of yours? YES NO If Yes, Please give full details Previous Insurer: Policy Number: Period of Insurance: From: To: History and Losses/claims for last three years: 2. Should any of the above information be incorrect or should there be any other material fact (that would have influence our decision to offer a quote or terms of the quote) that has not been disclosed, then urgent contact should be made by the insured to rectify the non- disclosure or incorrect information. The consequence of incorrect or inadequate declarations of material information can result in serious implications on coverage and claims payments. COVE EQUIED Page 1

2 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 (Please tick appropriate block) Section Class Cover equired Annual Premium 1 Fire YES NO 2 Building Combined YES NO 3 Office Contents YES NO 4 Business Interruption YES NO 5 Accounts eceivable YES NO 6 Theft YES NO 7 Money YES NO 8 Glass YES NO 9 Fidelity YES NO 10 Goods in Transit YES NO 11 Business All isk YES NO 12 Accidental Damage YES NO 13 Employers Liability YES NO 14 Public Liability YES NO 15 Stated Benefits YES NO 16 Group Personal Accident YES NO 17 Motor YES NO 18 Motor Traders Internal YES NO 19 Motor traders External YES NO 20 Electronic Equipment YES NO 21 Machinery Breakdown YES NO 22 Machinery Breakdown BIS YES NO TOTAL ANNUAL PEMIUM Monthly Premium SASIA Broker Fee Total Monthly Premium CLIENT SIGNATUE SECTION 1. FIE ITEM DESCIPTION/ADDESS SUM INSUED Page 2

3 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Buildings ent (eceivable/payable) Plant, Machinery, Landlords Fixtures and Fittings and all other Contents Stock and materials in Trade Goods in the open Additional claims Preparation Costs ADDITIONAL PEILS TO BE INCLUDED Earthquake YES NO Special Perils (Storm, wind, water, hail YES NO Malicious Damage YES NO Leakage Limit equired.. YES NO Subsidence and Landslide (equires Engineers eport) YES NO iot and Strike Outside of SA YES NO Disposal of Salvage YES NO Escalation Specify Percentage. % YES NO SECTION 2. BUILDING COMBINED ITEM SUM INSUED Page 3

4 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Subsidence and Landslide (equires Engineers eport) YES NO iot and Strike Outside of SA YES NO Escalation Specify Percentage. % YES NO TOTAL SECTION3. OFFICE CONTENTS ITEM Contents Documents Liability for documents Additional Claims Preparation Costs SUM INSUED Theft by Forcible and Violent entry YES NO Limit Theft Extension YES NO Limit NB COMPUTE EQUIPMENT IS EXCLUDED UNDE THIS SECTION SECTION4. BUSINESS INTEUPTION ITEM SUM INSUED 1. Gross Profit(Difference Basis) 2. Gross Profit(Additions Basis) 3. evenue 4.Additional Increase in Cost of Working 5.Wages (Number of Weeks Basis) Number of Weeks: Page 4

5 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 6.Fines and Penalties 7.Additional claims Preparation Costs 8.Other INDEMNITY PEIOD (SPECIFY NUMBE OF MONTHS) Months Suppliers/Subcontractors (specified) YES NO..% of sum insured by items 1 to5 Suppliers/Subcontractors (unspecified) YES NO..% of sum insured by items 1 to5 Prevention of access Extended Cover YES NO Customers (Specified) YES NO..% of sum insured by items 1 to5 Public Utilities- Insured Perils YES NO Public Telecommunications- Insured Perils YES NO Public Utilities Extended Cover YES NO Public Telecommunications- Extended Cover YES NO SECTION 5. ACCOUNTS ECEIVABLE ITEM Outstanding Debt Balance Additional Claims Preparation Costs Total SUM INSUED Transit Extension YES NO Limit iot and Strike Outside SA YES NO Limit Note: Declaration of outstanding debt balance to be made within 60 days Of the end of the month to which they refer. SECTION 6. THEFT ITEM(Premises to be specified) FIST LOSS Page 5

6 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Additional Claims Preparation Costs SECUITY OF PEMISES Burglar Bars YES NO Security gates YES NO Controlled Access YES NO 24 Hour Guards YES NO Linked Alarm with Armed esponse YES NO If YES, to Alarm Service Provider Total Damage to Building, as result of attempted theft- increase limit YES NO Limit SECTION 7. MONEY ITEM(Premises to be specified) Limit required during any other specified period: Details Total MAJO LIMIT eceptacles YES NO Limit Additional Claims Preparation Costs YES NO limit iot and Strike Outside of SA YES NO Personal Accident Assault YES NO No of Persons Capital Sum Page 6

7 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Weekly Sum Medicals SECTION 8. GLASS ITEM(Premises to be specified) Additional Claims Preparation Costs MAJO LIMIT Special einstatement YES NO iot and Strike Outside SA YES NO Sum Insured SECTION 9. FIDELITY GUAANTEE Name or Position Basis Page 7 SUM INSUED

8 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Total Blanket Basis Number of Employees Additional Claims preparation Costs etroactive cover YES NO Superseded Policy (...years) YES NO Voluntary First Amount Payable.. YES NO einstatement of Sum insured YES NO Cost of ecovery limit.. YES NO Computer losses YES NO Losses discover 24 months after they have been committed but not more YES NO than 36 months thereafter Extension granted on receipt of satisfactory system audit in respect of losses discovered more than 24 months after being committed YES NO If YES, attach copy of System Audit eport and state name of accounting firm SECTION 10. GOODS IN TANSIT Specify vehicle(load limit Basis) Page 8 SUM INSUED

9 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Total All goods to be insured Annual Carry basis Annual Carry Limit per Conveyance Means of Conveyance Additional Claims Preparation Costs SPECIFY THE TYPE OF COVE EQUIED All isk YES NO Fire, Explosion, Collocation, Derailment and Overturning Limitation YES NO Debris emoval Limit. YES NO iot and Strike Outside of SA YES NO Fire Extinguishing Charges YES NO Increase Fire Extinguishing Charges YES NO SECTION 11. BUSINESS ALL ISK ITEM DESCIPTION/ADDESS SUM INSUED Page 9

10 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 eplacement value Conditions YES NO Increased Cost of Working YES NO Sum insured iot and Strike Outside SA YES NO Additional Claims preparation Costs YES NO Sum insured SECTION 12. ACCIDENTAL DAMAGE ITEM DETAILS SUM INSUED 1. All property as defined in the section Total Value O 2. First Loss Premises Leakage of Oils/Chemicals/Fumes YES NO Sum insured Additional Claims preparation Costs YES NO Sum insured SECTION 13. PUBLIC LIABILITY Basis of Cover Claims Made YES NO If YES, state etroactive Date Occurrence YES NO SPECIFIED PEMISES LIMIT OF INDEMNITY Product Liability YES NO Limit Defective Workmanship YES NO Limit Legal defence Costs/Wrongful Arrest/Defamation YES NO Page 10

11 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 EEC Liability YES NO ISK QUESTIONNAIE NEEDS TO BE COMPLETED FO PODUCT LIABILITY AND DEFECTIVE WOKMANSHIP SECTION 14. EMPLOYES LIABILITY (Claims made basis only) etroactive Date LIMIT OF INDEMNITY SECTION 15. STATED BENEFITS ITEM DESCIPTION/OCCUPATION CICUMSTANCES ITEM NO/COMPENSATION Death Times annual salary Permanent Disability Times annual salary Temporary total disability % % % % % Average weekly salary For a period longer than weeks But no longer than weeks Medical Expenses Burns Disfigurement Extension YES NO Business Hours Limitation YES NO SECTION 16. GOUP PESONAL ACCIDENT ITEM Page 11 NAME/DESCIPTION/OCCUPATION

12 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / CICUMSTANCES ITEM NO/COMPENSATION Death Permanent Disability Temporary total disability Per week For a period longer than weeks But no longer than weeks Medical Expenses Burns Disfigurement Extension YES NO Business Hours Limitation YES NO SECTION 17. MOTO YEA/MAKE/MODEL EGISTATION NUMBE VINN NUMBE ENGINE NUMBE COVE COMPEHENSIVE T.P.F.T T.P SECUITY IS THE VEHICLE VSS COMPLIANT Y N FACTOY FITTED ALAM Y N FITTED WITH A IMMOBILISE Y N FITTED WITH A GEA LOCK Y N TACKING DEVICE Y N NO CLAIM BONUS IF FITTED WITH TACKING DEVICE SEVICE POVIDE DETAILS VALUE EXTAS(to be added to value) Contingent Liability YES NO Passenger Liability YES NO Parking facilities YES NO Windscreen YES NO Loss of keys YES NO Page 12

13 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 YEA/MAKE/MODEL EGISTATION NUMBE VINN NUMBE ENGINE NUMBE COVE COMPEHENSIVE T.P.F.T T.P SECUITY IS THE VEHICLE VSS COMPLIANT Y N FACTOY FITTED ALAM Y N FITTED WITH A IMMOBILISE Y N FITTED WITH A GEA LOCK Y N TACKING DEVICE Y N NO CLAIM BONUS IF FITTED WITH TACKING DEVICE SEVICE POVIDE DETAILS VALUE EXTAS(to be added to value) Contingent Liability YES NO Passenger Liability YES NO Parking facilities YES NO Windscreen YES NO Loss of keys YES NO YEA/MAKE/MODEL EGISTATION NUMBE VINN NUMBE ENGINE NUMBE COVE COMPEHENSIVE T.P.F.T T.P SECUITY IS THE VEHICLE VSS COMPLIANT Y N FACTOY FITTED ALAM Y N FITTED WITH A IMMOBILISE Y N FITTED WITH A GEA LOCK Y N TACKING DEVICE Y N NO CLAIM BONUS IF FITTED WITH TACKING DEVICE SEVICE POVIDE DETAILS VALUE EXTAS(to be added to value) Contingent Liability YES NO Passenger Liability YES NO Parking facilities YES NO Windscreen YES NO Loss of keys YES NO YEA/MAKE/MODEL Page 13

14 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 EGISTATION NUMBE VINN NUMBE ENGINE NUMBE COVE COMPEHENSIVE T.P.F.T T.P SECUITY IS THE VEHICLE VSS COMPLIANT Y N FACTOY FITTED ALAM Y N FITTED WITH A IMMOBILISE Y N FITTED WITH A GEA LOCK Y N TACKING DEVICE Y N NO CLAIM BONUS IF FITTED WITH TACKING DEVICE SEVICE POVIDE DETAILS VALUE EXTAS(to be added to value) Contingent Liability YES NO Passenger Liability YES NO Parking facilities YES NO Windscreen YES NO Loss of keys YES NO YEA/MAKE/MODEL EGISTATION NUMBE VINN NUMBE ENGINE NUMBE COVE COMPEHENSIVE T.P.F.T T.P SECUITY IS THE VEHICLE VSS COMPLIANT Y N FACTOY FITTED ALAM Y N FITTED WITH A IMMOBILISE Y N FITTED WITH A GEA LOCK Y N TACKING DEVICE Y N NO CLAIM BONUS IF FITTED WITH TACKING DEVICE SEVICE POVIDE DETAILS VALUE EXTAS(to be added to value) Contingent Liability YES NO Passenger Liability YES NO Parking facilities YES NO Windscreen YES NO Loss of keys YES NO YEA/MAKE/MODEL EGISTATION NUMBE VINN NUMBE Page 14

15 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 ENGINE NUMBE COVE COMPEHENSIVE T.P.F.T T.P SECUITY IS THE VEHICLE VSS COMPLIANT Y N FACTOY FITTED ALAM Y N FITTED WITH A IMMOBILISE Y N FITTED WITH A GEA LOCK Y N TACKING DEVICE Y N NO CLAIM BONUS IF FITTED WITH TACKING DEVICE SEVICE POVIDE DETAILS VALUE EXTAS(to be added to value) Contingent Liability YES NO Passenger Liability YES NO Parking facilities YES NO Windscreen YES NO Loss of keys YES NO SECTION 18. MOTO TADES INTENAL TO BE EFEED FO QUOTATION SECTION 19 MOTO TADES EXTENAL TO BE EFEED FO QUOTATION SECTION 20. ELECTONIC EQUIPMENT ITEM DESCIPTION SUM INSUED NB LAPTOPS HAS TO BE SPECIFIED PEMISES Consequential loss YES NO If YES, please provide the following details: Increased Cost of working- Sum Insured Indemnity period max of months einstatement of data- Sum Insured Page 15

16 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 Telkom Access lines YES NO Additional Claims Preparations Costs YES NO Sum Insured Incompatibility YES NO SECTION 21. MACHINEY BEAKDOWN TO BE EFEED FO QUOTATION SECTION 22 MACHINEY BEAKDOWN Business Interruption Section TO BE EFEED FO QUOTATION DECLAATION: I warrant that the answers given are true and correct and I do not know of any material facts even though specific questions about them have not been asked that should be communicated to ACE underwriters. I have never been refused insurance for the risk I now wish to insure nor have I had any policy in which I have or had an interest cancelled or restricted. The person completing this request to quote and proposal on my behalf does so as my agent. I AGEE THAT the request to quote and proposal shall be the basis of the contract between the underwriter and myself. I UNDESTAND THAT will not start until the proposal has been accepted by the underwriters. If you are unable to sign this declaration without qualification, please state your reason below: Authorised Signature Date Page 16

17 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 DEBIT ODE EQUEST AUTHOISATION FOM EPIC a division of Insurance Outsourcing Managers (Pty) Ltd Name (Insured): Date: Address: Dear Sirs/Madams, The details of my bank account are as follows: BANK: BANCH/TOWN: ACC NAME: BANCH NO: ACC. NO.: TYPE OF A/C: (Savings, current, transmission) I/we hereby request and authorise you to draw against my/our account with the abovementioned bank the sum of (my/our monthly insurance premium/s or any variable amount pertaining to this agreement), on the 1 st / 1st / 2nd / 3rd / 4th / 5th / 6th / 7th / 8th / 9th / 10th / 11th / 12th / 13th / 14th / 15th (please circle the applicable date) day of each and every month. This being the amount necessary for the payment of the monthly premium/payment due to you in respect of our insurance contract/agreement. All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally. I/we the undersigned, "instruct" and authorize your agent EPIC, to draw against my/our account Page 17

18 P O Box , Gardenview, 2047, epublic of South Africa Company egistration Number: 2014 / / 07 with the abovementioned bank, I/we understand that the withdrawals authorized here will be processed by First National Bank and I/we also understand that details of each withdrawal will be printed on my/our bank statement. I/we agree to pay any bank charges relating to this debit order instruction. This authority may be cancelled by means of giving you thirty days notice in writing, but I/we understand that I/we shall not be entitled to any refund of amounts, which you have withdrawn whilst this authority was in force if such amounts were legally owing to you. Signed on this day of 20 SIGNATUE AS USED FO SIGNING CHEQUES Page 18