Car Allowance Scheme Insurance Registration Form
INSURANCE POLICY NO ESK 2007/8 MAL / Unique Identifier / 240-46568741
Revision / Rev. 0
Shared Services
INITIALS AND SURNAME / PERSONNEL NO.
New Vehicle / Allowance Level (C / X / M)
Amendment / Dx X-Scheme Car Level
CAR DETAILS
DOCUMENTS REQUIRED / ·  Copy of Driver’s Licence
·  Copy of Vehicle Registration Papers / ·  Copy of Eskom’s Driver’s Permit
·  Copy of HP Contract
Plate Number / Insured Date
Are you the registered owner? / Yes / No / Registered Owner Name *
Make / Model
Category
Date of first registration / Construction Year / Odometer Reading
Vehicle ID Number / Engine Number
Date of Purchase / Insurance Val Ran / to
Radio Make & Model / Radio Value
Phone Kit Make & Model / Phone Kit Value
Vehicle Modifications / Modification Value
Any modifications of a non-standard nature not indicated on the HP contract should be advised to Human Resources with
proof of the purchase and cost.
Finance Company / HP Account Number
Outstanding Lease Val. / Medical declaration required if HP amount exceeds R500 000. Insurance
cover provided up to R1 000 000 (refer to CRS if vehicle value exceeds
R1 000 000.
Alarm / Immobiliser? / Yes / No / Details of Alarm / Immobiliser
Vehicle in garage or locked behind gates overnight? / Yes / No
Provide the address where the vehicle is usually parked overnight
Street / District
City / Postal Code
Please mark that you are aware of the following (Information available from local HR Offices)
√ / Drivers licensed / √ / Comprehensive Cover / √ / Cover Social / Eskom / √ / Insured all extras
Mark the following if applicable / √ / Outstanding Lease Value > R300K / √ / Vehicle Value > R1mil
Did you have a motor insurance claim from any insurance company during the past 3 years? / Yes / No
Please provide details of past 3 years insurance claims
Loss Date / Details of Incident / Cost
1.
2.
3.
4.
5.
EMPLOYEE
I, the undersigned, declare that the information provided above is true and correct.
Initials and Surname (print) / Signature / Date
VERIFIED BY HUMAN RESOURCES
Date of Registration / Date Captured
HR Administrator’s Initials and Surname / Signature
Data Checked By / Signature
* If the vehicle is not registered in the employee’s name the life insurance cover in force, which gives cover on the death, or permanent
disablement of the employee falls away in totality in respect to the total outstanding hire purchase or lease amount.
FDiv Layout Portrait Template Rev. 0.doc
Page 1 of 2 / PUBLIC / TE – F1000,
Effective February 2010