OMNI TRANSPORTER ~ PROPOSAL FORM / QUOTATION REQUEST Broker Name e-mail Telephone Sub-Broker Name PROPOSER DETAILS If more space is requird to any of the below questions, please attach another page recording details, date and sign the document Proposer Name Trading Name Previous Trading Name[s] Business description Company Registration Number VAT Number Type of Organisation [Tick one] Pty Ltd Close Corporation Sole Proprietor Trust How long have you been a transporter? Physical Address Code Postal Address Code Telephone Number Fax Number e-mail address Cell Phone INSURANCE HISTORY Current Previous Previous Name of Insurer Policy Number Has any Insurer declined to quote? Yes No Has any Insurer cancelled your insurance? Yes No Has any Insurer refused to renew your policy? Yes No Has any insurer required an increase in premium / or imposed special terms? Yes No If yes to any of the questions, please provide full details: DRIVER DETAILS Owner Driver? Yes No Are drivers salaried / weekly paid? Yes No Are drivers paid for each delivery or for each kilometre? Yes No Do you employ drivers who are not South African Citizens? Yes No Do you check drivers PrDP and DDC Licences every year? Yes No Do you maintain details of drivers PrDP and DDC Licences [copies held]? Yes No Do your drivers always drive the same vehicle/horse and trailer? Yes No Do your drivers attend to a pre-start check list, and the record is kept? Yes No Are previous driving and employment records investigated prior to employment? Yes No Do you have any in-house driving programmes in place? Yes No Do you have any external driving programmes in place? Yes No Please provide details of drivers aged below 25 and over 60 years of age and/or have less than three years driving experience DRIVERS NAME ID NUMBER LICENCE/EXPERIENCE DETAILS DRIVER TRAINING Have drivers been formally trained in the following? Correct operation of the vehicle being driven? Yes No Correct securing of the load? Yes No Procedures following an accident? Yes No Security of the vehicle and trailer? Yes No Hijacking prevention measures? Yes No Fire-fighting measures? Yes No First Aid Yes No Taking rest periods as required? Yes No 1
COMMUNICATION AND SECURITY Do any of the vehicles have the following fitted or installed? Cellular phones Yes No Two-way radio s Yes No Tachnograph Yes No Dry Powder Extinguishers Yes No Anti-hijacking devices Yes No Automatic engine cut out Yes No Driver Telematics System Yes No Vehicle/Trailer overloading devices Yes No Insurer approved Vehicle Tracking system Yes No Fleet management systems Yes No Registration number captured on the roof Yes No ABS braking system Yes No ADDITIONAL INFORMATION SPECIFY Other safety and protection devices/systems fitted Protection measures at the premises where vehicles are kept TRAVELLING DISTANCE AREAS OF OPERATION OUTSIDE RSA Short haulage up to 100km % % Medium haulage 110km 400km % % Long haulage 401km 800km % % Extremely long haulage 801km 2000km % % Into neighbouring territories over 2001 km % % MOTOR FLEET INFORMATION Motor section on a fleet basis Please indicate the fleet information below, over the past three (3) years: [If more space is required, please attach another page recording details, date and sign the attached document] YEAR TOTAL NUMBER OF VEHICLES FULL VALUE OF THE FLEET Motor section on a specified basis Kindly add an inventory with full vehicle details i.e.: Make/Model/Year/Registration/VIN/Vehicle Value [including value of all accessories] and the Registered Owner VEHICLE OPERATIONS Are any of the vehicles owned or operated by anyone other than yourself? Yes No Are any of the vehicles lent out or leased out, or control assigned to any other party? Yes No Are any of the vehicles in an unsafe, damaged and/or un-roadworthy condition? Yes No Does your Company perform its own servicing? Yes No Does your Company perform its own accident repairs? Yes No If Yes to any of the above, please provide detail: DETAILS OF THE EXCESS Details of excess structure the past 3 years [If more space is required, please attach another page recording details, date and sign the document] DETAILS OF NON-CONVENTIONAL INSURANCE Details of any non-conventional insurance arrangements over the past 3 years (if applicable) 2
DETAILS OF AGGREGATE EXCESS AND/OR BURNER Details of any non-conventional insurance arrangements over the past 3 years (if applicable) PREVIOUS MOTOR CLAIMS History of previous claims/losses (for past 3 years) as confirmed by the Insurer [If more space is required, please attach another page recording details, date and sign the document]: Date of Loss Type of vehicle Vehicle registration Description of loss Settlement amount DRIVERS ~ MULTIPLE CLAIMS Please provide details of all drivers who had more than one claim during the last three years NAME OF DRIVER ID NUMBER CORRECTIVE ACTION TAKEN GOODS IN TRANSIT INFORMATION Do you require goods in transit cover? Yes No Conveyance Limits A] Maximum value any one load R B] Maximum value at any one warehouse whilst in the course of transit R C] Annual Haulage fees in respect of the previous financial year R D] Estimated / projected annual haulage fees in respect of the current financial year R Foodstuffs Tobacco Electrical appliances Buildings materials Bricks / pavers Steel products Fertiliser s Vehicles Fuel Gas Shipping Containers Wild Game Agricultural Livestock / Bloodstock Shipping Containers Fresh Produce If Other, please describe: DESCRIPTION OF GOODS AND PERCENTAGE OF LOAD CARRIED DESCRIPTION % DESCRIPTION % Liquor Hazardous Chemicals Electronics Heavy Equipment Machinery Steel / Cables Sand, stone, aggregate,coal,cement,bricks Fragile or White Goods Explosives Household / Office moving Furniture [new] Furniture [used] Clothing Refrigerated / Frozen goods Dangerous goods Other 3
PREVIOUS GOODS IN TRANSIT CLAIMS History of previous claims/losses (for past 3 years) as confirmed by the Insurer [If more space is required, please attach another page recording details, date and sign the document]: BUSINESS ALL RISKS INFORMATION Do you require business all risks cover? Yes No ITEM VALUE PREVIOUS BUSINESS ALL RISKS CLAIMS History of previous claims/losses (for past 3 years) as confirmed by the Insurer [If more space is required, please attach another page recording details, date and sign the document]: IMPORTANT NOTICE: 1) Claims Notification and/or Theft/Hijacking All claims are to be reported on an Omnicover Pty Ltd claim form. In an event of theft or hijack, and as soon as the occurrence is known, IMMEDIATELY NOTIFICATION must be given to: JOHN PEARSON and ASSOCIATES (071 623 5499 - HOTLINE) Omnicover Pty Ltd must be notified as soon as possible but no later than two working days after the occurrence. Take all reasonable steps to recover the stolen property and to discover the guilty party. Advise Omnicover Pty Ltd of any claim (other than theft, hijack) as soon as possible but no later than THIRTY DAYS after the occurrence. In the case of a serious claim where damage to the insured vehicle is likely to exceed R200 000 (Two hundred thousand rand) or more than one third party is involved in the event, IMMEDIATE NOTIFICATION must be given to: KVTR (0800 430 430) Inform the South African Police Service as soon as possible and in any event not later that 24 (twenty four) hours following the accident or theft of property. Complete the claim form as soon as possible and provide Omnicover Pty Ltd with all material information as requested like Telematics report / vehicle movements at the time of loss. The insurer will be under no obligation to proceed with a claim if you cannot provide, in full, the required information. Provide Omnicover Pty Ltd with material proof, information, sworn declarations and any other documentation that the insurer may require as soon as practicable. Provide Omnicover Pty Ltd with particulars of any other insurance that covers the same events as any section of Omnicover Policy. Immediately forward to Omnicover Pty Ltd any notice of a claim, communication, writ, summons or other legal process issued or commenced against you in connection with the occurrence. 4
2) Theft/Hi-jacking Condition of cover in terms of all type vehicles (excluding Trailers and Special Type vehicles): All vehicles as defined with an Insured Value of R200 000 and above must be protected with an approved operative tracking device. If a tracking device is installed, loss of or damage to the vehicle following theft, hijacking or attempted theft or hijacking will be covered only if; a) At the occurrence of a claim the Policyholder must supply proof of such tracking and recovery device and that it was activated at the time of the loss (A fourteen day grace period is allowed for the installation of the device from the date that cover incepted in instances where the vehicle does not have an approved tracking and recovery device installed) b) The Policyholder must ensure that the tracking device is operational and maintained in a good working order and that the device is tested at least once every six months; c) The theft or hijacking is immediately reported to the supplier of the required tracking device; 3) Alteration of Risk Should there be a material change in the risk which increases the exposure to the Company in any way during the period of insurance, the Insured shall immediately inform the Company thereof, who will be entitled to review the terms of the policy 4) Fire Extinguishers All heavy type commercial vehicles, medium commercial vehicles and plant items covered by the Omnicover Pty Ltd policy must be fitted with a minimum of a 4.5kg dry powder fire extinguisher. 5) Towing Companies For vehicle towing services please use CTS [Car Towing Services] who can be contacted on 0861 869 464 5
DEBIT ORDER AUTHORISATION AND BANK ACCOUNT DETAILS IMPORTANT INFORMATION: Please ensure that sufficient funds are available to make the contractual transfer. Banks will levy a penalty fee on your account if there are insufficient funds. The premium will be transferred monthly from your nominated account to the Oakhurst Insurance Company Limited account, on the same day of the month as selected below. Always keep an amount in your bank account higher than the amount that will be debited to provide for normal bank charges. Day of month on which deductions must be made, select one * 1 7 10 15 *If your debit date falls on a weekend, your bank will debit your account on the preceding working day. Accountholder: Bank: Branch: Account Number: Branch Code: Account Type: Cheque/Current Savings Transmission DEBIT ORDER AUTHORITY: I, the undersigned, request Oakhurst Insurance Company Limited to draw against my account the debit order amount. Such withdrawals from my account will be treated as though they have been signed by me personally, and I request the bank to debit my account with these drawings in line with all the conditions specified in this form. DATE: SIGNED BY NSURED: 6
Declaration The proposal must be completed and signed by the proposer/insured. The proposal shall form the basis of the insurance contract between the insured and the insurer, Oakhurst Insurance Company Limited, on acceptance thereof by both parties. Making any false statement[s] or withholding any material facts may give the Insurer the right to reject any claim made under the policy or may result in the policy being declared null and void from the inception. A material fact is any fact that will influence the acceptance of the risk. I/We declare that the statements and particulars in this Proposal Form are true to the best of our knowledge and belief and that I/We have not misstated, suppressed or omitted any material facts. I/We agree that this Proposal Form together with any other information supplied by us shall form the basis of any contract of Insurance effected thereon and shall be incorporated therein. I/We undertake to inform Insurers of any material alteration of these facts whether occurring before or after completion of the contract of Insurance. Signing this Proposal Form does not bind the Proposer to complete this Insurance. I/We acknowledge that if this proposal is accepted, the contract of insurance will be subject to the terms and conditions as set out in the policy wording as issued or as otherwise specifically varied in writing by Omnicover Pty Ltd I/We who is employed by the proposer, confirm that I/We are authorised by the Company to complete and sign this Proposal Form and Debit Order Authorisation. Signed: Full Names Print]: Capacity: Date: 7