TI Brokers is a proud member of the Insurance Institute of South Africa

Quote Request Form

Personal Information


General

Have you as the Insured; or your spouse, or any person that may be living with you, or any other person that may at any
time drive any of the vehicles stated in this policy in any capacity?


Excess


Domestic Buildings Section


R
If THATCH (including thatch lapa), please note that the thatch application has to accompany this proposal

Please provide any details of any claims or losses suffered by you during the past five years, whether insured or not

DATE

DESCRIPTION

AMOUNT

R
R
R

SETTLED

Household Contents Section


R

If THATCH (including thatch lapa), please note that the thatch application has to accompany this proposal

Please provide any details of any claims or losses suffered by you during the past five years, whether insured or not

DATE

DESCRIPTION

AMOUNT

R
R
R

SETTLED

Personal Liability Section

Limit of Liability is R3 000 000 (three million rand) which is automatically added to your policy


All Risk Section

Please specify any items that should be specified under the all risk section


DESCRIPTION

MAKE

MODEL

SERIAL NUMBER

VALUE

Please provide any details of any claims or losses suffered by you during the past five years, whether insured or not

DATE

DESCRIPTION

AMOUNT

R
R
R

SETTLED

Vehicle Insurance Section

Cars, Trailers, Caravans, Boats


Vehicle 1

Vehicle 2

Vehicle 3

Year

Make

Model

Engine No

VIN No

Registration No

Vehicle Code

Registered Owner

Registered Owner's ID & Relationship to Insured

Regular Driver

Regular Driver's ID & Relationship to Insured

Occupation of Driver

Marital Status of Driver

Year Drivers License Obtained

License Code

Have you completed any defensive driving course?

Will anyone else drive the vehicle?

Name of Driver

Driver's ID & Relationship to the Insured

Occupation of Driver

Marital Status of Driver

Year Drivers License Obtained

License Code

Have you completed any defensive driving course?

Type of Use

Average kilometres traveled per month

Type of Cover

Security Fitted in Vehicle

Any extras fitted & value

Do you require these extras to be insured?

Car radio cover required?

If Yes, please provide further details

Is the vehicle modified/converted?

If Yes, please provide further details

Address where vehicle is kept at night

Is the vehicle in a locked garage or behind locked gates at night?

Address where vehicle is kept during the day

What security is in place at the risk address during the day?


Credit Shortfall

(Purchase Invoice Required)


Do you require car hire?

If MANUAL

If AUTOMATIC

If EXECUTIVE

Excess Structure

Has the vehicle been purchased through:

Interest of Financial Institution:

(Purchase invoice required)

Are you insured on any other vehicle insurance at the moment?

Please advise the cancellation date of the above policy

Have you had continuous insurance in the last five years?

If no, please provide further details

Current/Previous Insurer

Policy No:

Reason for Cancellation:

Have you or any other drive of the vehicle/s ever had their drivers license endorsed or cancelled?

If yes, please provide further details

Please provide details of any claims or losses suffered by you during the past five years, whether insured on any policy or not

DATE

DESCRIPTION

AMOUNT

SETTLED

Special instructions:

Personal Accident Section


Do you require the insurance?

The age limits for acceptance under this section are 18 to 75 years

PERSONS TO BE INSURED

Name & Surname

Occupation

ID Number

Relationship to the insured

Death

(Compulsory Benefit)

Permanent Disablement

(Maximum not to exceed death benefit)

Temporary Total Disablement

(Maximum 52 Weeks)

(Maximum R10 000/week)

Medical Expenses

(Maximum R10 000)

In respect of persons to be insured (PLEASE ANSWER ALL QUESTIONS FULLY)

Please give full details of all injuries which any of the persons to be insured have incurred (giving dates & duration)


DATE

DESCRIPTION

Please provide any details of any claims or losses suffered by you during the past five years:

DATE

DESCRIPTION

AMOUNT

SETTLED

The Beneficiary

In respect of any claim consequent upon your death, we will pay the benefit to the beneficiary nominated by you and named in the schedule


Special Risk


0

Valuation


Address
Mowbray, Fourways Golf Park, Roos Street,
Fourways, Gauteng,
South Africa
Telephone
+27 10 600 9999
Trading Hours
08:30 to 16:30
email
insurance@tibrokers.biz

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