BnB Sure Proposal and questionnaire

Transcription

1 BnB Sure Proposal and questionnaire Information Broker FSP number Insured name (legal name) Company registration VAT number Contact person ID number Establishment name Postal address Street address where establishment is situated Postal code Postal code Cellphone number Telephone number Facsimile number (if different) Website address Type of establishment B&B Guesthouse Backpacker Other (specify) Would you like to be listed on the BnB Finder website? Yes No NAA/GHASA/BABASA/FEDHASA/Chambers Accom/Nightsbridge or AA Travel Guides member? Yes No If yes, which association Association membership number Is the establishment star graded? Yes No If yes, number of stars When do you want the insurance to commence? All documentation is sent electronically for security purposes. General (Compulsory) Are some or all of your buildings thatch or non-standard? Yes No If yes, please specify dimensions of thatch cover Wall construction Floor construction If thatch, please complete the enclosed Thatch questionnaire. Do you have a restaurant or conference facility? Yes No If yes, describe the facility Zurich Insurance Company South Africa Limited 15 Marshall Street, Ferreirasdorp, Johannesburg, 2001 PO Box 61489, Marshalltown, 2107 Telephone No egistration No. 1965/006764/06 Zurich is an authorised Financial Services Provider No of 12

2 Number of seats in restaurant Is the restaurant part of the main building? Yes No Does the actual or estimated turnover of this facility exceed 40% of your total turnover? Yes No If yes, what percentage % Does the facility comply with the requirements of the Liquor Licensing Act? Yes No Do you offer restaurant and/or bar facilities to patrons other than your guests? Yes No Do you have conference facilities? Yes No If yes, how many delegates does the facility seat If these facilities are not within the main building, please give details Value of liquor contained in the restaurant Do you offer any activities to your guests other than a domestic gym, swimming pool, tennis or squash court? Yes No If yes, please describe these activities Do you cater for weddings? Yes No If yes, state the percentage of turnover from this service % If yes, state the maximum number of guests per event What is the overall annual turnover for the establishment? What is the percentage split on items listed below Accommodation % Tours % estaurant % Conference facilities % Weddings % Spa facilities % Other (please specify) % How many bedrooms do you have? Guest Other Do you have any dormitory type rooms? Yes No If yes, please give details Is your establishment classified as a holiday home? Yes No If yes, how long is the holiday home rented out for during a 12-month period? How long has the establishment been in operation? Give details of telephone equipment on the premises Do you have employees permanently on the premises? Yes No Please supply details of the security at your establishment If you have a manager running the premises and his/her possessions are to be insured, please give the name Do you have a trampoline on the premises for use by guests? Yes No If yes, is there a disclaimer displayed at the trampoline? Yes No Do you keep any animals other than domestic dogs and cats and caged birds? Yes No 2 of 12

3 If yes, please state what animals Do you have prominently displayed or signed disclaimers at the premises? Please supply a copy Yes No Do you transport customers other than guests staying at the establishment? Yes No Do you have a PDP and COF license? Yes No Comfort heat sources emarks Coiled wire bar heaters? Yes No Fireplaces? Yes No Electric heaters? Yes No Sprinklers (if applicable) emarks Weekly alarm test(s) completed and recorded? Yes No Weekly pump test(s) completed and recorded? Yes No Sprinkler heads clear of obstructions? Yes No Sprinkler control valve(s) open? Yes No Clear access to sprinkler control valve(s)? Yes No Fire sprinkler pumps (if applicable) emarks Diesel tank full? Yes No Control panel lights working? Yes No Power supplies to control panels on? Yes No Control panels switched to automatic? Yes No Weekly pump tests performed? Yes No Fire hydrants emarks Clear access? Yes No Hydrants, hoses and nozzles in good condition? Yes No Hose reels (if applicable) emarks Clear access? Yes No In good condition? Yes No Serviced within last 12 months? Yes No Extinguishers emarks All present and correctly located? Yes No Clear access? Yes No In good condition? Yes No Serviced within last 12 months? Yes No Staff trained to use fire equipment? Yes No Smoking emarks Smoking controls observed? Yes No Smoke detection in rooms? Yes No Fire doors emarks Self closing mechanism intact? Yes No Doors can be closed manually? Yes No Unlocked whilst premises is occupied? Yes No Break-glass keybox near any emergency exit door locked with a key? Yes No 3 of 12

4 Gas cylinders emarks Fittings and hoses in good condition? Yes No Installed by accredited LPGASA installer? Yes No Total kg gas kept on site Kitchen emarks Cooker hood in use? Yes No Cooker hood filters serviced regularly? Yes No Deep fryer in use? Yes No Fire blanket near cooking appliance? Yes No Fire extinguisher in kitchen? Yes No Security emarks External doors closed where required? Yes No External doors/locks in good condition? Yes No Type of intruder prevention system adio linked? Yes No Security systems operational? Yes No Perimeter fence/wall intact? Yes No Patrolmen on site? Yes No Area well lit at night? Yes No Outside goods stored well away from buildings? Yes No Electrical emarks Permanent electrical wiring used/no extension leads? Yes No Electrical fittings in good condition? Yes No All appliances plugged into their own outlet? Yes No Public safety emarks Swimming pool on site? Yes No Pool fenced? (if applicable) Yes No Indemnity signs posted? Yes No Evacuation signs posted in each room? Yes No Evacuation plan in place and formalised? Yes No Are employees aware of their duties in an evacuation? Yes No Emergency numbers displayed/available? Yes No Are you aware of any incidents which have arisen in the past 12 months which could give rise to a claim? Yes No If yes, please give details Do you comply with all fire regulations required by local authorities? Yes No With which insurer were you previously insured? (Personal and business insurances) In what year was the establishment constructed? Has any insurer ever cancelled any policy you have held whether personal or business? Yes No If yes, please tell us why 4 of 12

5 Give full details of all losses or claims suffered (whether insured or not) in the past three years Type of loss (fire, motor, all risks, burglary, accident etc.) Year Cost (approx.) I confirm that the information contained in this questionnaire/proposal is true and that this document will form the basis of my contract with Zurich Insurance Company South Africa Limited. Date: Signature: Debit order form Account holder Bank Account number Branch Branch code Type of account Please indicate what date between the 1st and 7th of every month we should debit your account for the premium collection. If possible, please attach a copy of a cancelled cheque. Collection date of debit order I authorise Zurich Insurance Company South Africa Limited to debit my account with the monthly premiums due for my BnB Sure policy. Date: Signature: Buildings section Do you wish to insure your buildings? Yes No If these are to be insured, what is the current replacement value? Cover required Comprehensive Fire and perils only Number of geysers Size of geysers Do you have retaining walls? Yes No If yes, please specify Subject to an approved engineers report and management approval. Do you require power surge cover in excess of the free 22,500? Yes No If yes, please specify Contents section (Compulsory) What is the total replacement value of the entire contents including both personal and business? (Minimum 100,000) 5 of 12

6 Cover required Comprehensive Fire and perils (with extensions) Fire and perils (without extensions) Do you wish to insure the personal effects of guests in excess of the free 25,000 whilst at your premises and where they are not otherwise insured? Yes No If yes, to what value (Maximum 200,000) Do you wish to insure all your electrical goods against power surge in excess of the free 22,500? Yes No Value of total electrical goods Do you require Bilking cover in excess of the free 25,000 offered under Contents? Do you wish to increase to 30,000 or 40,000? Yes No Value to be insured Liability section (Compulsory) 30,000,000 Limit of liability required 50,000, ,000,000 Do you require spread of fire cover? Yes No If yes, please complete the enclosed Spread of fire questionnaire. Guests medical evacuation section Do you wish to insure your guests for a medical evacuation? Yes No 10,000 Limit required 50, ,000 Money section Money (cash, cheques etc.) can be insured on premises and in transit to and from the bank. Do you wish to insure money? Yes No If yes, state amount All risks section Do you wish to insure any general unspecified items e.g. personal effects, clothing etc. whilst you have them away from your premises? Yes No If yes, for what amount (Minimum 3,000) Single articles are limited to 25% of this sum insured. The term personal effects excludes sunglasses in excess of 250, contact lenses, firearms, car sound systems, tape decks and tapes, laptop or hand-held computers and the like, compact discs, pedal cycles, cellular phones and pagers. These should be specified separately if cover is required Please note we need a valuation for any item in excess of 2,000 in value. 6 of 12

7 Electronic section Do you wish to insure any computer or other electronic equipment? Yes No If yes, please give details (please list laptop computers separately) Do you require reinstatement of data? Yes No If yes, to what value Do you require increased cost of working? Yes No If yes, to what value Business interruption section If you were to close your business following a fire, flood or storm, a murder, rape or suicide or the death of a key member of the establishment, would you like financial assistance to cover this loss? Yes No If yes, what amount of gross annual income would you lose? per year Indemnity period 3 months 6 months 9 months 12 months Would you like SASIA cover under the Business interruption section? Yes No Standing charges Working expenses Motor section Do you wish to insure your vehicles? Yes No If yes, please complete the following Vehicle 1 Vehicle 2 Vehicle 3 Make Model Year egistration number VIN number Engine number Current retail value Date purchased Finance company Finance account number Shortfall included Yes No Yes No Yes No New New New How is vehicle registered Used Used Used ebuilt ebuilt ebuilt Stolen/recovered Stolen/recovered Stolen/recovered 7 of 12

8 Extras or modifications Vehicle 1 Vehicle 2 Vehicle 3 egistered owner Main driver Main driver s date of birth Date license first issued Drivers license code Other regular drivers Current no claim bonus Area where used Cover required Comprehensive Third party fire and theft Third party only Comprehensive Third party fire and theft Third party only Comprehensive Third party fire and theft Third party only Vehicle security and make Usual overnight parking Is the car garaged at night? Yes No Yes No Yes No Car radios are not included here. Please specify non-factory fitted car radios under the All risks section. Optional cover to motor section Do you require basic excess waiver? Yes No Do you require car hire following an accident? Yes No Do you require 5,000,000 unspecified personal accident cover? Yes No Covers any passenger (excluding any person in the employ of the insured or family of the insured) being transported in the insured s vehicle, injured in a motor accident and where the insured is clearly to blame. Extended passenger liability section Do you require 5,000,000 extended passenger liability cover? Yes No This cover is required if game drives or tours are offered to guests. (The vehicle used must be insured on this policy). Pleasurecraft section Do you wish to insure your boats? e.g. yachts, speedboats, rubber ducks, jetski s etc. Yes No (Maximum 100,000) Manufacturer Engine Sum insured 8 of 12

9 Fidelity section Do you require cover in excess of the free 10,000 cover? Yes No If yes, how much Personal accident, critical illness and income protection section Applicable to persons between the ages of 18 and 70 only. Do you wish to insure this section? Yes No To the best of your knowledge are all the persons to be insured for personal accident in good health, free from physical defects, or infirmities, and not especially exposed to accidents from their occupations or past-times? Yes No If no, please give details Proposer name and initials Date of birth Disabilities Cover required Proposer 1 Proposer 2 Proposer 3 Section 1: Personal accident insurance Death Permanent total disablement Temporary total disablement number/ wages per week Section 2: Accident medical expenses Accident medical expenses Section 3: Critical illness Critical illness Section 4: Income protection Income protection requirement per month Section 5: Motor personal accident Death Permanent total disablement Notes a) Section 1 minimum cover for items 1 and 2 for 100,000. b) Section 2 for 25,000, 50,000 or 100,000. c) Section 3 is available for 50,000 only. d) Sections 2 and 3 may only be taken together with section 1. e) Section 5 any amount up to 5,000,000 crucial cover for the insured in motor accident. f) Cover is excluded whilst the insured person is engaged in steeplechasing, waterpolo, winter sports (involving snow or ice), professional football, mountaineering, motorcycling, racing of any kind (involving the use of any power-driven vehicles, vessels, aircraft or pedal cycle), big-game hunting or any sport or past-time involving exceptional risk of accident. g) Special cover for servants can be obtained. Please refer to BnB Sure for details. Tax and CPA legal costs section Do you wish to have insurance on tax and CPA legal costs? Yes No If yes, specify annual limit 120, ,000 Are you currently undergoing any investigation by SAS? Yes No Are you expecting a refund from SAS? Yes No Do you have any outstanding debts with SAS? Yes No 9 of 12

10 Are you up-to-date with all your VAT and PAYE? Yes No Are all your tax returns up-to-date and submitted? Yes No How much of your business as a percentage is cash business? % Have you familiarised yourself with the Consumer Protection Act and how it pertains to your business? Yes No Do you have legally acceptable disclaimers in place? Yes No When you receive a deposit as confirmation of booking, is the consumer provided with information concerning a cancellation process? Yes No Appliance maintenance section (Compulsory) Domestic type of appliances and electronics as per policy wording are insured on a first loss basis for repairs up to a limit of 3,000. Portable items and industrial commercial type equipment may not be included. Household motors such as pool motor/jacuzzi/electric gate/electric garage door motors can be included at an additional premium of 9 per motor. Do you require this additional cover? Yes No If yes, please specify Solar panels can also be included at an additional premium of 12 per item. Do you require this additional cover? Yes No If yes, please specify 10 of 12

11 Thatch questionnaire (for quotation purposes only) Full name Postal address Full risk address Postal code Postal code Telephone number Facsimile number Does the kitchen have a ceiling of material other than thatch? Yes No If yes, state type of material Type of thatched roof (e.g. straw, Cape reed) If solid fuel is used, i) are open fires used? Yes No ii) are chimneys fitted with spark arrestors? Yes No Are there trees surrounding the thatched risk? Yes No If yes, are they higher than the roof? Yes No Does the building have a lightning conductor/strike masts? Yes No If yes, is it SABS approved? Yes No Any wiring passing through the thatch? Yes No How far are the premises from the nearest fire brigade? kilometres Has the thatch been treated with any fire retardant measures e.g. fire blankets, Thatchsayf? Yes No Is the building protected by a drencher system? Yes No If yes, state whether manual or automatic What other precautions have been taken against fire? What is the name of your thatching company? Are surrounding grounds (within 25 metres or the boundary perimeter, whichever is the closer) free of all bush, jungle, grass and weeds, other than normal garden cultivation? Yes No Values to be insured for thatch Buildings (including outbuildings, tennis courts, swimming pools, walls, gates, fences and driveways) Contents (excluding all risks items) Loss of revenue (gross annual revenue) 11 of 12

12 Spread of fire questionnaire (for quotation purposes only) A. Proposers details Full name of insured isk address and name of farm Type of farming Size of insured s farm Width of fire breaks Frequency of burning Time of year of burning Precautions whilst burning Wind directions at time of burning Type of fire fighting equipment Previous claims/losses Postal code B. Neighbouring farm details Name of owners and the name of farms To north To south To east To west Type of farm To north To south To east To west Previous claims/losses I hereby declare that all particulars and answers in the questionnaire are true and complete in every respect, and that no material fact has been withheld. Date: Signature: 12 of 12