Client Proposal Form – Refiloe Wealth

Good Faith
We believe in treating all policyholders fairly and to act professionally, honestly and with due care and diligence. We also rely on the honesty and integrity of our policyholders in this mutual partnership to help us accurately assess risk and determine premium. We underwrite risk based on the information provided to us at quote stage, at policy inception stage as well as every time circumstances change that could affect your risk in any way. This document, your policy schedule, all declarations, communications and proposals made by you, or on your behalf forms part of the insurance contract that will be the reference point when assessing claims.
Brokerage name		Quotation number
Broker name		Broker Telephone number
Broker Id number		Broker email address

Policy Sections Applied For
Buildings/Homeowners YesNo	Personal Liability YesNo
Householders/Content YesNo	Personal Computers YesNo
Motor YesNo	Personal Accident YesNo
Motorcycles YesNo	Hybrid Help YesNo
Caravans & Trailers YesNo	Crime Assist YesNo
Watercraft YesNo	Car Hire YesNo
All Risk YesNo	Self-Insure Fund YesNo

Supporting Documents Attached (where Applicable)
Proof of previous Insurance YesNo	Proof of claims history YesNo
Pre-inspection certificate YesNo	Survey documentation YesNo
FICA (if Self-Insure fund selected) YesNo

Personal Details Of Policy Holder
Title
Full Names
Surname
Marital Status
Occupation
RSA citizen?
If no which country?
ID Number
ID Number
Tel No. (W)
Tel No. (H))
Fax No
Cell No
Email Address
Address
Code

Claims/Losses Declaration
Are you currently comprehensively insured?		YesNo
If yes, for how long have you had uninterrupted insurance?
Who is your current insurer?	Policy number
Who was your previous insurer?	Policy number
Have you as the insured, or your spouse, or any other person that may be living with you, or any other person that may at any time drive any of the vehicles stated in the policy
a) Been declared insolvent, under judicial management, credit counselling		YesNo
b) Has any judgment been made against you/ or any person mentioned in the policy?		YesNo
c) Any criminal convictions, a criminal record or any criminal cases pending		YesNo
d) Been refused motor insurance		YesNo
e) Has had their driving licence endorsed or suspended		YesNo
f) Suffered from any physical defect or infirmity		YesNo
If Yes, please provide details
Are you aware of any material information, requested or not, that could affect the risk of this proposal?		YesNo
If Yes, please provide details

Full Information Regarding Losses And/or Claims Which Occurred In The Past 3 Years
	Insurer & Policy Number/Description of Loss/Claim	Date	Amount
1
2
3
4
5
6
7
8

Cover Information
Residence 1 Address
Address Code:
Property use (tick appropriate option):			Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune
Construction and property type:
Roof:
Walls:
Type of property
Security:			Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)
Full subsidence & Landslip cover? (If yes, please note that a geo survey will be required)			YesNo
General information: Unoccupied more than 60 days p/a?			YesNo
Unoccupied more than 30 consecutive days during any year?			YesNo
Unoccupied more than 7 consecutive days in first 45 days of cover?			YesNo
Sum insured Required
Residence 2 Address
Address Code:
Property use (tick appropriate option):			Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune
Construction and property type:
Roof:
Walls:
Type of property
Security:			Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)
Full subsidence & Landslip cover? (If yes, please note that a geo survey will be required)			YesNo
General information: Unoccupied more than 60 days p/a?			YesNo
Unoccupied more than 30 consecutive days during any year?			YesNo
Unoccupied more than 7 consecutive days in first 45 days of cover?			YesNo
Sum insured Required

2. Content Section
Residence 1 Address
Address Code:
Property use (tick appropriate option):			Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune
Construction and property type:
Roof:
Walls:
Type of property
Security:			Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)
Accidental Damage			YesNo
Sum Insured
Subsidence & Landslip			YesNo
Current NCB/CFG:
General information: Unoccupied more than 60 days p/a?
Unoccupied more than 30 consecutive days during any year?
Unoccupied more than 7 consecutive days in first 45 days of cover?
Sum insured Required
Residence 2 Address
Address Code:
Property use (tick appropriate option):			Main ResidenceHoliday HomeBusinessSecondary residenceProperty let outSecond dwellingCommune
Construction and property type:
Roof:
Walls:
Type of property
Security:			Linked AlarmAlarm not linkedElectric FenceSecurity DoorsBurglar barsHigh security complex (24hr guards)
Accidental Damage			YesNo
Sum Insured
Subsidence & Landslip			YesNo
Current NCB/CFG:
General information: Unoccupied more than 60 days p/a?
Unoccupied more than 30 consecutive days during any year?
Unoccupied more than 7 consecutive days in first 45 days of cover?
Sum insured Required

3. All Risk Section
Unspecified All Risk / Blanket cover
Under unspecified/blanket cover the item limit is 25% of the total sum insured for the section. (Example: If the sum insured is R100 000, then maximum claim per item would be R25 000)
Specified Item	Serial Number	Insured Amount









Vehicle sound equipment (not factory fitted), Cellular Phones, tablets, laptops, pedal cycles, sunglasses, stamp or coin collections, caravan contents, camping gear, golf clubs, firearms, GPS equipment, fishing gear etc must be insured under the All Risk Section, regardless of the value. Proof of ownership by means of invoice or valuation certificate must be made available on all claims

1. Motor / Motorcycles
	Vehicle 1
Type of Vehicle: (No carrying of commercial / trade goods)		Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike
Year of Manufacture
Make and Model
Engine Number
Vin Number
Registration Number
Registered owner full names
Registered owner id number
Regular Driver Name
Regular Driver ID no
Regular Driver NCB / CFG
Occupation of driver
VEHICLESLicence year (mmyyyy) & type:		Type
Interest of Financial Institution
Type of use		PrivateBusiness
Security Fitted in vehicle: (Tracking units need to be installed within 14 days from inception otherwise cover will be limited to 3rd party cover)		Approved tracking unitTracking unit to be installedAlarm VESA approvedImmobiliser VESA approved
Rebuild / code 3 vehicle			YesNo
Performance modified			YesNo
Non- Factory fitted Accessories	Item description	Value





Overnight Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Daytime Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
	Vehicle 2
Type of Vehicle: (No carrying of commercial / trade goods)		Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike
Year of Manufacture
Make and Model
Engine Number
Vin Number
Registration Number
Registered owner full names
Registered owner id number
Regular Driver Name
Regular Driver ID no
Regular Driver NCB / CFG
Occupation of driver
VEHICLESLicence year (mmyyyy) & type:		Type
Interest of Financial Institution
Type of use		PrivateBusiness
Security Fitted in vehicle: (Tracking units need to be installed within 14 days from inception otherwise cover will be limited to 3rd party cover)		Approved tracking unitTracking unit to be installedAlarm VESA approvedImmobiliser VESA approved
Rebuild / code 3 vehicle			YesNo
Performance modified			YesNo
Non- Factory fitted Accessories	Item description	Value





Overnight Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Daytime Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates

2. Motor Section Additional Vehicles
	Vehicle 3
Type of Vehicle: (No carrying of commercial / trade goods)		Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike
Year of Manufacture
Make and Model
Engine Number
Vin Number
Registration Number
Registered owner full names
Registered owner id number
Regular Driver Name
Regular Driver ID no
Regular Driver NCB / CFG
Occupation of driver
VEHICLESLicence year (mmyyyy) & type:		Type
Interest of Financial Institution
Type of use		PrivateBusiness
Security Fitted in vehicle: (Tracking units need to be installed within 14 days from inception otherwise cover will be limited to 3rd party cover)		Approved tracking unitTracking unit to be installedAlarm VESA approvedImmobiliser VESA approved
Rebuild / code 3 vehicle			YesNo
Performance modified			YesNo
Non- Factory fitted Accessories	Item description	Value





Overnight Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Daytime Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
	Vehicle 4
Type of Vehicle: (No carrying of commercial / trade goods)		Sedan / Hatch / Coupe / SUVLDV / Pick UpRoad MotorcycleOff road Motor cycleQuad Bike
Year of Manufacture
Make and Model
Engine Number
Vin Number
Registration Number
Registered owner full names
Registered owner id number
Regular Driver Name
Regular Driver ID no
Regular Driver NCB / CFG
Occupation of driver
VEHICLESLicence year (mmyyyy) & type:		Type
Interest of Financial Institution
Type of use		PrivateBusiness
Security Fitted in vehicle: (Tracking units need to be installed within 14 days from inception otherwise cover will be limited to 3rd party cover)		Approved tracking unitTracking unit to be installedAlarm VESA approvedImmobiliser VESA approved
Rebuild / code 3 vehicle			YesNo
Performance modified			YesNo
Non- Factory fitted Accessories	Item description	Value





Overnight Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Daytime Parking of vehicle			Access controlled basementBehind locked gates uncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gatesAccess controlled basementBehind locked gates uncovered

3. Caravan/Trailer Section
Caravan / Trailer 1			CaravanTrailerOff road trailerMotorbike trailerBoat trailer
Year of Manufacture
Caravan / Trailer Make and Model
Overnight Parking of vehicle			Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Daytime Parking of vehicle			Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Market value
Caravan / Trailer 2			CaravanTrailerOff road trailerMotorbike trailerBoat trailer
Year of Manufacture
Caravan / Trailer Make and Model
Overnight Parking of vehicle			Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Daytime Parking of vehicle			Access controlled basementBehind locked gatesuncoveredBehind locked gates coveredLocked garageStreet unsecuredSecurity complex 24hr guardsIn yard -no locked gates
Market value

4.Pleasure/ Watercraft Section
Type of vessel – Vessel 1			Inflatable boat / rubber duckMotorboat inland <9mBow rider <9mCabin boat <9mMotorboat coastal <9mSail boat <9MWindsurfer
Year of Manufacture
Make and model of the vessel
Serial / HIN number
Engine/s – Type of engine			InboardOutboard
Number of Engine/s
Make of engine/s
Horse power
Year of Manufacture
Replacement value
Serial NR
Hull
Replacement value
Material of Hull
Is the vessel self-built?			YesNo
Accessories to be noted	Serial Number	Replacement Value