Get A Quote – TI Brokers

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

The truth is often one's best shield

- James Rollins

Who We Are

Quote Request Form

I Would Like A Quotation For:

Personal Information

Title

Full Names

Surname

ID No.

Marital Status

Work Number

Home Number

Cell Number

Occupation

Fax Number

Preferred Method of Communication

Postal Address

Address Line 1

Address Line 2

City

Province

Postal Code

Risk Address (Where Goods Are Kept)

Address Line 1

Address Line 2

City

Province

Postal Code

Are You a South African Citizen?

Yes

If No, Which Country Are You a Citizen Of?

COMMENCEMENT DATE OF POLICY

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?

A - Been Declared Insolvent?

Yes

B - Had any judgements, sequestration or financial administration orders made against You / any person mentioned on this policy?

Yes

C - Are there any pending judgements, sequestration or financial administration orders made against You / any person mentioned on this policy?

Yes

D - Have a criminal record?

Yes

E - Are there any pending criminal investigations against You / any person mentioned on this policy?

Yes

F - Have a physical defect i.e. vision, hearing, epilepsy etc?

Yes

G - Has any insurance company ever cancelled or applied any special conditions to a policy of yours or your spouse / any person mentioned on this policy?

Yes

If yes to any of the above, please provide further details

Excess

Is an Excess waiver across the whole policy required (no under 30’s)?

Yes

Domestic Buildings Section

Sum Insured

Type of Residence

If OTHER, please specify

Construction - Roof

Construction - Walls

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

Physical Address

Code

Do you currently have insurance on your buildings?

Yes

Current / Previous Insurer & Policy Number

Bondholder

Do you require extended subsistence and landslip cover?

Yes

Do you require power surge cover?

Yes

If yes, please indicate

R10000

R20000

R30000

R40000

R50000

Is the residence occupied during working hours?

Yes

If yes, please provide further details:

Is the residence occupied by anyone other than the insured or insured’s family?

Yes

If yes, please provide further details:

Will it be unoccupied for 4 consecutive days within the next 60 days?

Yes

If yes, please provide further details:

Will the residence be unoccupied for more than 60 days a year?

Yes

If yes, please provide further details:

Is the residence in an established built-up area?

Yes

Are there any new building developments nearby?

Yes

Is the residence on a small holding, farm, or plot?

Yes

If yes, please provide further details:

Is the residence next to a vacant piece of land?

Yes

Is the residence currently vacant?

Yes

If yes, please provide further details:

Is the residence being lent, let or sublet?

Yes

If yes, please provide further details:

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

DATE

DESCRIPTION

AMOUNT

SETTLED

Yes

Household Contents Section

Sum Insured

Risk Address

Type of Residence

If Other, please specify

If the residence is a holiday home, how long will it be unoccupied for?

Please provide further details as to when the holiday home will be occupied and by whom.

Are there security and caretaking\housekeeping measures in place at the holiday home?

Yes

If yes, please provide further details:

Construction - Roof

Construction - Walls

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

Do you require extended subsidence and landslip cover?

Yes

Are all opening windows protected by burglar bars?

Yes

Are all external doors protected by security gates?

Yes

Are there any sliding doors at the residence?

Yes

Are the sliding doors protected by security gates?

Yes

Are the sliding doors fitted with an additional locking mechanism?

Yes

Please provide details of the additional locking mechanism fitted to the sliding door/s

Is there a burglar alarm system installed at your residence?

Yes

If yes, is the alarm linked to an armed response company?

Yes

Is the alarm in working order?

Yes

Is the alarm activated when the residence is unoccupied?

Yes

Are all opening windows and external doors protected by the alarm / sensor?

Yes

Name the armed response company:

Is the residence situated in an estate?

Yes

Does the estate have 24 hour access control?

Yes

Is the estate enclosed with electric fencing?

Yes

Are there 24 hour guards stationed at the estate?

Yes

Are there any factors not mentioned above that may adversely affect the security risk of your residence?

Yes

If yes, please provide further details:

Are there any additional security features not mentioned above, that may improve the security of your residence?

Yes

If yes, please provide further details:

Is the residence occupied during working hours?

Yes

If yes, please provide further details:

Is the residence occupied by anyone other than the insured or insured’s family?

Yes

If yes, please provide further details:

Will the residence be unoccupied for 4 consecutive days within the next 60 days?

Yes

If yes, please provide further details:

Will the residence be unoccupied for more than 60 days a year?

Yes

If yes, please provide further details:

Do you conduct any business from the residence?

Yes

If yes, what type of business?

Do clients have access to the residence?

Yes

Do you store any stock for the business?

Yes

If yes, please provide further details:

Is any money kept on the premises with regard to the business?

Yes

If yes, please specify the amount:

Is the residence in an established built-up area?

Yes

Are there any new developments nearby?

Yes

Is the residence on a smallholding, farm or plot?

Yes

If yes, please provide further details:

Is the residence near a park, a sports field or golf course?

Yes

If yes, please provide further details (km distance):

Is the residence next to a vacant piece of land?

Yes

Is the residence being lent, let or sublet?

Yes

If yes, please provide further details:

Do you currently have insurance for your contents?

Yes

Current/previous insurer and policy no:

Have there been any burglaries at this risk address?

Yes

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

DATE

DESCRIPTION

AMOUNT

SETTLED

Yes

Personal Liability Section

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

Do you require Supplementary Liability at an additional premium?

Yes

R10 000 000 (Ten million rand)

R20 000 000 (Twenty million rand)

All Risk Section

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

DESCRIPTION

MAKE

MODEL

SERIAL NUMBER

VALUE

Special Instructions

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

DATE

DESCRIPTION

AMOUNT

SETTLED

Yes

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?

Radio Field

Yes

Will anyone else drive the vehicle?

ADDITIONAL_DRIVER_YN

Yes

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?

Radio Field

Yes

Type of Use

Radio Field

Strictly Private

Social (Inc to Work & Back)

Business

Professional Business

Radio Field

Strictly Private

Social (Inc to Work & Back)

Business

Professional Business

Radio Field

Strictly Private

Social (Inc to Work & Back)

Business

Professional Business

Average kilometres traveled per month

Text Input

Type of Cover

Radio Field

Comprehensive

Third Party, Fire & Theft

Third Party Only

Radio Field

Comprehensive

Third Party, Fire & Theft

Third Party Only

Radio Field

Comprehensive

Third Party, Fire & Theft

Third Party Only

Security Fitted in Vehicle

Checkbox Field

Anti-Hijack

Tracking

Immobiliser

Alarm

Transponder Key

Checkbox Field

Anti-Hijack

Tracking

Immobiliser

Alarm

Transponder Key

Checkbox Field

Anti-Hijack

Tracking

Immobiliser

Alarm

Transponder Key

Any extras fitted & value

Text Input

Do you require these extras to be insured?

Radio Field

Yes

Radio Field

Yes

Radio Field

Yes

Car radio cover required?

CAR_RADIO_COVER1

Yes

CAR_RADIO_COVER2

Yes

CAR_RADIO_COVER3

Yes

If Yes, please provide further details

Make

Model

Insured Value

Make

Model

Insured Value

Make

Model

Insured Value

Is the vehicle modified/converted?

CAR_MOD_1

Yes

CAR_MOD_2

Yes

CAR_MOD_3

Yes

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?

Yes

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)

Yes

Amount

Yes

Amount

Yes

Amount

Do you require car hire?

Yes

If MANUAL

30 DAYS

60 DAYS

30 DAYS

60 DAYS

30 DAYS

60 DAYS

If AUTOMATIC

30 DAYS

60 DAYS

30 DAYS

60 DAYS

30 DAYS

60 DAYS

If EXECUTIVE

30 DAYS

60 DAYS

30 DAYS

60 DAYS

30 DAYS

60 DAYS

Excess Structure

Standard

Excess Buster (Does not apply to under 30s)

Flat Excess (Does not apply to under 30s)

Standard

Excess Buster (Does not apply to under 30s)

Flat Excess (Does not apply to under 30s)

Standard

Excess Buster (Does not apply to under 30s)

Flat Excess (Does not apply to under 30s)

Has the vehicle been purchased through:

DEALERSHIP

PRIVATE SALE

FINANCE HOUSE

DEALERSHIP

PRIVATE SALE

FINANCE HOUSE

DEALERSHIP

PRIVATE SALE

FINANCE HOUSE

Interest of Financial Institution:

(Purchase invoice required)

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

Yes

Please advise the cancellation date of the above policy

Have you had continuous insurance in the last five years?

Yes

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?

Yes

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?

Yes

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

Is there any other additional Personal Accident cover in force?

Yes

If yes, please provide further details

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

DATE

DESCRIPTION

AMOUNT

SETTLED

Do any of the persons to be insured suffer from defective vision or hearing from any physical or mental condition?

Yes

If yes, please provide further details

Have the insured persons undergone any operation of any sort in the past?

Yes

If yes, please provide further details

Current status of health

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

Name

ID Number

Special Risk

Do you require Emergency Home Assist Cover?

Yes

Do you require Motor Assistance Cover?

Yes

Name Of Complex or Estate

Number of Units

Construction

Construction Type (if other)

Structure of Building

Structure (if other)

Security of the Complex

Security (if other)

Number Of Geysers

Size of Geysers

Size of Geyser (if other)

Type of Geyser

Valuation

Date of Last Completed Valuation

Last Valuation Completed By

Upload - Last Valuation Document

Choose File

Please provide a detailed description of each selection in the fields provided in order to receive the most accurate quoting experience.

Should more information be required, we will contact you

Please Select All That Apply

Lifts

Thatched Areas

Retaining Walls

Wooden Huts

Boreholes

Transformers

Sumps & Pumps

Tanks

Reticulation

None / Other

Number of Lifts

Details of Thatched Areas

Details of Retaining Walls

Details of Wooden Huts

Number of Borehole/s

Details of Transformers

Details of Sumps & Pumps

Details of Tank/s

Details of Reticulation

List Details if Other

Would You Like to Include Fidelity or Professional Indemnity Insurance?

Yes

First Name

Last Name

Contact Number

Email Address

Upload - Current Insurance Policy In Place

Choose File

Upload - Last Three Years' Claim History

Choose File

Additional Notes

Upload - Additional Information

Choose Files

Name of Managing Agent

Managing Agent EAAB Certificate Number

Managing Agent NAMA Membership Number

Managing Agent Company or CC Registration

Does the Managing Agent hold Fidelity Cover, covering your funds?

Yes

If "Yes" what is the amount of Fidelity cover held by the managing agent?

Does the Managing Agent hold Professional Indemnity Cover, covering your funds?

Yes

If "Yes" what is the amount of Professional Indemnity cover held by the managing agent? (min R1m per scheme managed required)?

Address

Mowbray, Fourways Golf Park, Roos Street,
Fourways, Gauteng,
South Africa

Telephone

+27 10 600 9999

Trading Hours

08:30 to 16:30

insurance@tibrokers.biz

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