NAVIGATE HHG & PE SHIPMENT QUESTIONAIRE (ONE OFF)

NAVIGATE HHG & PE SHIPMENT QUESTIONAIRE (ONE OFF) INSURED / PROPOSER: TOTAL INSURED VALUE OF SHIPMENT: Voyage - From (Country and City) -To (Country and City) DATE OF DEPARTURE - Method of Conveyance - Rail Road Sea Freight Air freight OWNER PACKED: YES / NO PROFFESSIONALLY PACKED: YES / NO Other information we should know aout that might influence this Insurance? Completed By - NAME IN PRINT SIGNED DATE

Valued Inventory LOUNGE : DINNING ROOM : Furniture R Furniture R Loose Lamps R Loose carpets R China & Glassware R Curtains & Fittings R Silverware R China & Glassware R Television R Silverware R Hi-fi & Records R Cutlery & Taleware R Radio/Tape Deck/Tape R Pictures & Ornaments R Piano R Lamps & Electrical Fittings R Pictures & Ornaments R Liquor R Lamps & Electrical Fittings R Appliances R Miscellaneous R Miscellaneous R STUDY : FAMILY ROOM : Furniture R Furniture R Loose carpets R Loose carpets R Curtains & Fittings R Curtains & Fittings R Lamps & Electrical Fittings R China & Glassware R Books R Silverware R Pictures & Ornaments R Television R Hi-fi & Records R Hi-fi & Records R Radio/Tape Deck/Tape R Radio/Tape Deck/Tape R Television R Piano R Pictures & Ornaments R Video Machine R Lamps & Electrical Fittings R

Computer, Printer, Fax/Related R Miscellaneous R KITCHEN / PANTRY: ALL BEDROOMS: Furniture R Furniture R Refrigerator/Contents R Loose carpets R Deep Freeze/Contents R Curtains & Fittings R Cooker R Bedding R Dish Washer R Clothing R Electrical Fittings R Lamps & Electrical Fittings R Cutlery R Pictures & Ornaments R China & Glassware R Miscellaneous R Cooking utensils R Curtains & Fittings R LINEN CUPBOARD: Food mixer R Clothing R Food R Household Linen R Miscellaneous R Miscellaneous R HALL / PORCH: LAUNDRY: Furniture R Curtains & Fittings R Loose Carpets R Washing Machine R Curtains & Fittings R Ironing Machine R Lamps & Electrical Fittings R Iron/s R Pictures & Ornaments R Electrical Fittings R Miscellaneous R Miscellaneous R BATHROOM: LOFT: Furniture R Furniture R Floor Covering R Trunks etc. R Curtains & Fittings R Miscellaneous R Electrical Fittings R GARAGE:

Miscellaneous R Electrical Fittings R TOOL SHED: Battery Charges R Lawn Mower R Bicycles R Garden Tools R Tools R General Tools R Miscellaneous R OTHER / SPECIFY: R OTHER / SPECIFY: R TOTAL RE ALL aove: R ( Please refer to quote as to whether cover 1, 2, 3 or 4 to apply ) COVER 1 HOUSEHOLD GOODS AND PERSONAL EFFECTS CLAUSE HGPE1 1 This insurance is against All Risks in terms of the Institute Cargo Clauses (A) or Institute Cargo Clauses (Air) so far as may e applicale and the Institute Replacement Clause. This insurance includes the risks of War and Strikes in terms of the relative Institute Clauses. NOTE: War risk only applicale if air or sea sending's. 2 EXCLUSIONS (in addition to those contained in the Institute Cargo Clauses as aove) a c d e f g Gradual deterioration, moths, vermin, rust, mildew, any process of cleaning or repair. Mechanical, electrical or electronic derangement unless actual reakage has occurred or other than as a direct result of fire, derailment, collision or overturning of the Conveying Vehicle or fire, stranding or collision of the Vessel. Consequential loss of any kind Depreciation resultant upon repairs for under this insurance. Detention from any cause or confiscation y Customs officials Jewellery, furs, watches, precious metals and stones, onds, cash, anknotes, deeds, stamps and securities; Manuscripts, documents, plans and computer systems records; liquor, wines, eer or any other alcoholic everages, Foodstuffs & plants. Containers other than suitcases or trunks properly cased. 3 DURATION OF COVER Clauses 8.1 to 8.1.3 of the Institute Cargo Clauses (A) and Clauses 5.1 to 5.1.3 of the Institute Cargo Clauses (Air) are deemed to e deleted and replaced y the following: The insurance attaches from the time the goods leave the warehouse, place of storage or Insured's domicile at the place named herein for the commencement of the transit and continues whilst at packers premises during the ordinary course of transit and terminates either: a On delivery to the Insured's domicile at the destination named herein. On delivery to Insured s premises and/or warehouse or place of storage whether prior to or at the destination which the Insured elects to use for storage other than in the ordinary course of transit whichever shall first occur. c The policy may e extended at additional premium to e agreed to include storage at a professional storage facility suject to: - Dedicated Storage Facilities to have required urglar proofing on all doors & windows/openings Functional c1 Alarm system with 24 hours response unit. c2 Premises to e fully fenced / secured & 24 hours armed guard security patrols c3 Must have Access control & monitored y CCTV / similar camera facilities c4 Suject to required fire prevention & functional fire extinguishing equipment c5 Maximum First Limit of Liaility of R 250 000 in respect of Theft and/or Burglary ex the storage facility 4 Warranted that the total value of china, glassware, marle, earthenware and similar rittle articles do not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Furthermore, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 500

5 Warranted that the total value of antique furniture does not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Also, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 2 000. 6 Average Clause: If the property covered y this insurance shall at the time of any loss or damage e of greater value than the sum insured herey, the Insured shall only e entitled to receive hereunder such proportion of the said loss or damage as the sum insured y this policy ears to the total value of the said property. 7 Pairs & Sets Clause: In the event of loss of and/or damage to any articles forming part of a pair or set, the Insurer's liaility shall e limited to the value of such part or parts which may e lost or damaged, without reference to any special value which such articles shall have as part of such pair or set, nor shall it exceed the proportionate part of the insured value of such pair or set. 8 In the event of damage to any article or any part thereof in respect of which there is a valid claim, the Insurers shall have the option of paying for the amount of the damage or having the article repaired or replaced in a reasonaly and sufficient manner COVER 2 HOUSEHOLD GOODS AND PERSONAL EFFECTS CLAUSE - HGPE2 (EXCLUDING BREAKAGE) 1 This insurance is against All Risks in terms of the Institute Cargo Clauses (A) or Institute Cargo Clauses (Air) so far as may e applicale and the Institute Replacement Clause. This insurance includes the risks of War and Strikes in terms of the relative Institute Clauses. NOTE: War risk only applicale in respect of air or sea sending's. 2 EXCLUSIONS (in addition to those contained in the Institute Cargo Clauses as aove) a c d e f g h Breakage, scratching, chipping, denting or ruising. Gradual deterioration, moths, vermin, rust, mildew, any process of cleaning or repair. Mechanical, electrical or electronic derangement unless actual reakage has occurred or other than as a direct result of fire, derailment, collision or overturning of the Conveying Vehicle or fire, stranding or collision of the Vessel. Consequential loss of any kind Depreciation resultant upon repairs for under this insurance. Detention from any cause or confiscation y Customs officials Jewellery, furs, watches, precious metals and stones, onds, cash, anknotes, deeds, stamps and securities; Manuscripts, documents, plans and computer systems records; liquor, wines, eer or any other alcoholic everages, Foodstuffs & plants. Containers other than suitcases or trunks properly cased. 3 DURATION OF COVER Clauses 8.1 to 8.1.3 of the Institute Cargo Clauses (A) and Clauses 5.1 to 5.1.3 of the Institute Cargo Clauses (Air) are deemed to e deleted and replaced y the following: The insurance attaches from the time the goods leave the warehouse, place of storage or Insured's domicile at the place named herein for the commencement of the transit and continues whilst at packers premises during the ordinary course of transit and terminates either: a On delivery to the Insured's domicile at the destination named herein. On delivery to Insured s premises and/or warehouse or place of storage whether prior to or at the destination which the Insured elects to use for storage other than in the ordinary course of transit whichever shall first occur. c The policy may e extended to include storage at additional premium to e agreed at a professional storage facility suject to: - Dedicated Storage Facilities to have required urglar proofing on all doors & windows/openings Functional c1 Alarm system with 24 hours response unit. c2 Premises to e fully fenced / secured & 24 hours armed guard security patrols c3 Must have Access control & monitored y CCTV / similar camera facilities c4 Suject to required fire prevention & functional fire extinguishing equipment c5 Maximum First Limit of Liaility of R 250 000 in respect of Theft and/or Burglary ex the storage facility 4 Warranted that the total value of china, glassware, marle, earthenware and similar rittle articles do not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Furthermore, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 500 5 Warranted that the total value of antique furniture does not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Also, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 2 000. 6 Average Clause: If the property covered y this insurance shall at the time of any loss or damage e of greater value than the sum insured herey, the Insured shall only e entitled to receive hereunder such proportion of the said loss or damage as the sum insured y this policy ears to the total value of the said property. 7 Pairs & Sets Clause: In the event of loss of and/or damage to any articles forming part of a pair or set, the Insurer's liaility shall e limited to the value of such part or parts which may e lost or damaged, without reference to any special value which such articles shall have as part of such pair or set, nor shall it exceed the proportionate part of the insured value of such pair or set.

8 In the event of damage to any article or any part thereof in respect of which there is a valid claim, the Insurers shall have the option of paying for the amount of the damage or having the article repaired or replaced in a reasonaly and sufficient manner COVER 3 HOUSEHOLD GOODS AND PERSONAL EFFECTS CLAUSE HGPE 3 1 This insurance is against perils as defined in terms of the Institute Cargo Clauses (B) with su clause 1.2.3 deleted. Extended to include theft following Fire Collision Overturning of conveying vehicle as well as hijacking cover. This insurance includes the risks of War and Strikes in terms of the relative Institute Clauses. NOTE: War risk only applicale if air or sea sending's. 2 EXCLUSIONS (in addition to those contained in the Institute Cargo Clauses (B) su clause 1.2.3 deleted a c d e Consequential loss of any kind Depreciation resultant upon repairs for under this insurance. Detention from any cause or confiscation y Customs officials Jewellery, furs, watches, precious metals and stones, onds, cash, anknotes, deeds, stamps and securities; Manuscripts, documents, plans and computer systems records; liquor, wines, eer or any other alcoholic everages, Foodstuffs & plants. Containers other than suitcases or trunks properly cased. 3 DURATION OF COVER a c Clauses 8.1 to 8.1.3 of the Institute Cargo Clauses (B) are deemed to e deleted and replaced y the following: The insurance attaches from the time the goods leave the warehouse, place of storage or Insured's domicile at the place named herein for the commencement of the transit and continues whilst at packers premises during the ordinary course of transit and terminates either: On delivery to the Insured's domicile at the destination named herein. On delivery to Insured s premises and/or warehouse or place of storage whether prior to or at the destination which the Insured elects to use for storage other than in the ordinary course of transit whichever shall first occur. The policy may e extended to include fire risk at additional premium to e agreed whilst in storage at a professional storage facility suject to required fire prevention & functional fire extinguishing equipment 4 Warranted that the total value of china, glassware, marle, earthenware and similar rittle articles do not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Furthermore, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 500 5 Warranted that the total value of antique furniture does not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Also, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 2 000. 6 Average Clause: If the property covered y this insurance shall at the time of any loss or damage e of greater value than the sum insured herey, the Insured shall only e entitled to receive hereunder such proportion of the said loss or damage as the sum insured y this policy ears to the total value of the said property. 7 Pairs & Sets Clause: In the event of loss of and/or damage to any articles forming part of a pair or set, the Insurer's liaility shall e limited to the value of such part or parts which may e lost or damaged, without reference to any special value which such articles shall have as part of such pair or set, nor shall it exceed toe proportionate part of the insured value of such pair or set. 8 In the event of damage to any article or any part thereof in respect of which there is a valid claim, the Insurers shall have the option of paying for the amount of the damage or having the article - repaired or replaced in a reasonale sufficient manner COVER 4 HOUSEHOLD GOODS AND PERSONAL EFFECTS CLAUSE HGPE4 1 This insurance is against All Risks in terms of the Institute Cargo Clauses (A) or Institute Cargo Clauses (Air) so far as may e applicale and the Institute Replacement Clause ut excluding loss of or damage to cargo as a direct result of fire and lighting which are specifically insured in terms of the Insured s domestic householder's policy. This insurance includes the risks of War and Strikes in terms of the relative Institute Clauses. NOTE: War risk only applicale if air or sea sending's. 2 EXCLUSIONS (in addition to those contained in the Institute Cargo Clauses as aove) a Gradual deterioration, moths, vermin, rust, mildew, any process of cleaning or repair. Mechanical, electrical or electronic derangement unless actual reakage has occurred or other than as a direct result of fire, derailment, collision or overturning of the Conveying Vehicle or fire, stranding or collision of the Vessel.

c d e f g Consequential loss of any kind Depreciation resultant upon repairs for under this insurance. Detention from any cause or confiscation y Customs officials Jewellery, furs, watches, precious metals and stones, onds, cash, anknotes, deeds, stamps and securities; Manuscripts, documents, plans and computer systems records; liquor, wines, eer or any other alcoholic everages, Foodstuffs & plants. Containers other than suitcases or trunks properly cased. 3 DURATION OF COVER Clauses 8.1 to 8.1.3 of the Institute Cargo Clauses (A) and Clauses 5.1 to 5.1.3 of the Institute Cargo Clauses (Air) are deemed to e deleted and replaced y the following: The insurance attaches from the time the goods leave the warehouse, place of storage or Insured's domicile at the place named herein for the commencement of the transit and continues whilst at packers premises during the ordinary course of transit and terminates either: a On delivery to the Insured's domicile at the destination named herein. On delivery to Insured s premises and/or warehouse or place of storage whether prior to or at the destination which the Insured elects to use for storage other than in the ordinary course of transit whichever shall first occur. c The policy may e extended to include storage at additional premium to e agreed at a professional storage facility suject to: - Dedicated Storage Facilities to have required urglar proofing on all doors & windows/openings Functional c1 Alarm system with 24 hours response unit. c2 Premises to e fully fenced / secured & 24 hours armed guard security patrols c3 Must have Access control & monitored y CCTV / similar camera facilities c4 Suject to required fire prevention & functional fire extinguishing equipment c5 Maximum First Limit of Liaility of R 250 000 in respect of Theft and/or Burglary ex the storage facility 4 Warranted that the total value of china, glassware, marle, earthenware and similar rittle articles do not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Furthermore, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 500 5 Warranted that the total value of antique furniture does not exceed 15% / fifteen percent of the total sum insured unless otherwise recorded y endorsement to this policy. Also, suject to an Independent Dealer s Valuation Certificate where single item s value exceed R 2 000. 6 Average Clause: If the property covered y this insurance shall at the time of any loss or damage e of greater value than the sum insured herey, the Insured shall only e entitled to receive hereunder such proportion of the said loss or damage as the sum insured y this policy ears to the total value of the said property. 7 Pairs & Sets Clause: In the event of loss of and/or damage to any articles forming part of a pair or set, the Insurer's liaility shall e limited to the value of such part or parts which may e lost or damaged, without reference to any special value which such articles shall have as part of such pair or set, nor shall it exceed the proportionate part of the insured value of such pair or set. 8 In the event of damage to any article or any part thereof in respect of which there is a valid claim, the Insurers shall have the option of paying for the amount of the damage or having the article - repaired or replaced in a reasonaly and sufficient manner Synopsis of Cover & Exclusions Cover 1 Institute Cargo Clauses (A) or Institute Cargo Clauses (Air) Fire, explosion, stranding, sinking, capsizing, jettison, general average, discharge at port of distress, collision of vessel, overturning and derailment Washing overoard, earthquake, total loss of package during unloading & volcanic eruption Breakage, theft, pilferage and non-delivery, leakage, contamination Main Exclusions Inadequate packing Ordinary leakage, loss of weight, wear and tear Inherent vice Delay Financial Default or Insolvency Gradual deterioration, moths, vermin, rust, mildew, any process of cleaning or repair. Mechanical, electrical or electronic derangement e.g recaliration of equipment etc unless caused y an insured peril. Consequential loss of any kind. (Resultant damage) Jewellery, furs, watches, precious metals and stones, onds, cash, anknotes, deeds, stamps and securities; Manuscripts, documents, plans and computer systems records; liquor, wines, eer or any other alcoholic everages, Foodstuffs & plants Containers other than suitcases or trunks properly cased Synopsis of Cover 2 Institute Cargo Clauses (A) or Institute Cargo Clauses (Air) ut excluding reakages

Cover & Exclusions Fire, explosion, stranding, sinking, capsizing, jettison, general average, discharge at port of distress, collision of vessel, overturning and derailment Washing overoard, earthquake, total loss of package during unloading & volcanic eruption Theft, pilferage and non-delivery, leakage, contamination Main Exclusions As per Cover 1 detailed aove plus- Breakage, scratching, chipping, denting or ruising Synopsis of Cover & Exclusions Cover 3 Institute Cargo Clauses (B) with Su Clause 1.2.3 Deleted Fire, explosion, stranding, sinking, capsizing, jettison, general average, discharge at port of distress, collision of vessel, overturning and derailment Washing overoard, earthquake, total loss of package during unloading & volcanic eruption Main Exclusions As per Cover 1 & 2 aove Synopsis of Cover & Exclusions Cover 4 Top Up cover This insurance is against Risks in terms of the Cover 1 ut excluding loss of or damage to cargo as a direct result of fire and lighting, which are specifically insured in terms of the Insured s domestic householders policy Main Exclusions As per Cover 1

STATUTORY NOTICE TO SHORT-TERM INSURANCE POLICYHOLDERS IMPORTANT - PLEASE READ CAREFULLY DISCLOSURE AND OTHER LEGAL REQUIREMENTS (This notice does not form part of the Insurance Contract or any other document) As a short-term insurance policyholder, or prospective policyholder, you have the right to the following information: 1. Aout the intermediary (insurance roker) (a) () (c) (d) (e) (f) Name, physical address and postal address and telephone numer. Legal status and any interest in the insurer. Whether or not in possession of professional indemnity insurance. Detail of how to institute a claim. Rand amount of fees and commission payale. Written mandate to act on ehalf of insurer. 2. Aout the insurer (a) Name, physical and postal address and telephone numers. () Telephone numer of compliance department of the insurer. (c) Details of how to institute a claim and/or complaint. (d) Type of policy involved. (e) Extent of premium oligations you assume as policyholder. (f) Manner of payment of premium, due date of premiums and consequences of non-payment. 3. Other matters of importance (a) You must e informed of any material changes to the information referred to in paragraph 1 and 2. () If the information in paragraphs 1 and 2 was given orally, it must e confirmed in writing within 30 days. (c) If any complaint to the intermediary or insurer is not resolved to your satisfaction, you may sumit the complaint to the Registrar of Short-term Insurance. (d) Polygraph or any lie detector test is not oligatory in the event of a claim and the failure thereof may not e the sole reason for repudiating a claim. (e) If premium is paid y deit order: i. it may only e in favour of one person and may not e transferred without your approval; and ii. the insurer must inform you at least 30 days efore the cancellation thereof, in writing, of its intention to cancel such deit order. (f) The insurer and not the intermediary must give reasons for repudiating your claim. (g) Your insurer may not cancel your insurance merely y informing your intermediary. There is an oligation to make sure the notice has een sent to you. (h) You are entitled to a copy of the policy free of charge. 4. Warning Do not sign any lank or partially completed application form. Complete all forms in ink. Keep all documents handed to you. Make note as to what is said to you. Don t e pressurised to uy the product. Incorrect or non-disclosure y you of relevant facts may influence an insurer on any claims arising from your contract of insurance. 5 Particulars of Short-term Insurance Omudsman who is availale to advise you in the event of claim prolems that are not satisfactorily resolved y the insurance intermediary and/or the insurer. PO Box 32334 BRAAMFONTEIN 2017 Tel: (011) 726 8900 Fax: (011) 726 5501

6 Particulars of Registrar of Short-term Insurance Financial Service Board Tel: (012) 428-8000 Fax: (012) 347-0221 PO Box 35655 MENLO PARK 0102 7. NOTE - You are required to complete, sign & return the original signed version of this document prior to the sending / shipping of the cargo