CSM INTERNATIONAL (PTY) Ltd
Insurance is our Mission
An Authorized Financial Service Provider i.t.o FAIS Act
FSP 13240
3 West Street, Sonneveld Estate, 1552
Cell | 083266 6246 P.O.Box 4264, Dalpark, 1543
Tel | (011)743-2888 / 2999 Email:
Fax | (011)742-1714 Web:
PERSONAL DETAILSTitle
Full First Names
Surname
Maiden Name
Marital Status / Single Married Divorced Widowed Separated Engaged Gender M F
ID/Passport Number / Country of Issue
Date of Birth
Contact Numbers
Home
Work
Cell
Fax
Email Address
ADDRESS
Residential
Postal Code
Correspondence
Postal Code
Business
Postal Code
DEDIT ORDER DETAIL
Account type / Cheque/Current account Savings Transmission Debit Account Credit Account
Collection date / 1 7 15 28
Name of Bank
Account Number
Branch Code
Initials
Surname/Company Name
Account Holder Relationship / Own Joint 3rd Party
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:
Been declared insolvent? Yes No
Had any judgements, sequestration or financial administration orders made against you/any Yes No
person mentioned in this policy?
Are there any pending judgements, sequestration or financial administration orders made Yes No
against you/any person mentioned in this policy.
Have a criminal record? Yes No
Are there any pending criminal investigations against you/any person mentioned in this Yes No
policy?
Have a physical defect i.e. vision, hearing, epilepsy etc. Yes No
Has any insurance company ever cancelled or applied any special conditions to a policy of Yes No
yours or your spouse/any person mentioned on this policy?
If “Yes” to any of the above, please provide further details:
DECLARATION
Information sharing:
1)I acknowledge that the sharing of insurance information for underwriting and claims purposes (including credit information) between Insurers is in the public’s interest as it enables Insurers to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims, thereby minimising premium increases.
2)On my behalf and on behalf of any person I represent herein, I hereby waive my right to privacy with regard to underwriting or claims information (including credit information) that I provide or that is provided by another person on my behalf in respect of any insurance policy or claim made or lodges by me.
3)I acknowledge that the insurance information provided by me may be stored in the shared database and used as set out above as well as for any decision pertaining to the continuance of my policy or the meetings of any claims I may submit.
4)I consent to such information being disclosed to any other insurance company or its agent.
5)I acknowledge that the information may be verified against legally recognised sources or databases.
6)I warrant that the answers given are true, and I do not know of any material facts, even though specific questions about them have not been asked, that should be communicated to CIB. I have never been refused insurance for risks I now wish to insure, nor have I had any policy in which I have had or had an interest in, cancelled or restricted.
7)I agree that this proposal shall be the basis of the contract between the Insurer and myself. I understand that CIB may disclose my claims information to other parties. I will accept the Insurer’s standard policy.
8)I understand that this insurance will not start this proposal has been accepted by the Insurers. If you are unable to sign this declaration, please give your reasons here:
HOUSEHOLDERS / Contents / Building
Sum Insured / R
Type of residence: Flat (Floor?) Townhouse, Farm, Plot, House, Estate, Cluster
Construction of walls (e.g. Brick)
Roof Construction (e.g. Tile)
Thatch Roof or Thatch Lapa? / Yes / No
(If yes, thatch application has to accompany this proposal) / Treated / Lightning Conductor
Do you conduct any business from the residence? / Yes / No / Type
Do you store any stock for the business at the residence? / Yes / No
Is any money kept on the premises with regards to the business? / Yes / No / Amount: R
Is the residence being lent, let or sublet? / Yes / No / By Who?
Is the residence occupied during the day? / Yes / No / By Who?
Is the residence occupied by anyone other than the insured or their family? / Yes / No / By Who?
Are there any vacant areas surrounding the property? E.g. Parks, fields? / Yes / No
Is the residence next to a vacant piece of land? / Yes / No
Is the residence in an established built-up area? / Yes / No
Are there any new building developments nearby? / Yes / No
Will the residence be unoccupied for more than 60 days a year? / Yes / No
Will the residence be unoccupied for 4 consecutive days within the next 60 days? / Yes / No
Are all opening windows protected by burglar bars? / Yes / No
Are all eternal doors protected by security gates? / Yes / No
Are there sliding doors at the residence? / Yes / No
Are the sliding doors fitted with an additional locking mechanism? / Yes / No
Is there a burglar alarm system installed at your residence? / Yes / No
If Yes, is the alarm linked to an armed response company? / Yes / No
Is the alarm in working order? / Yes / No
Is the alarm active when the residence is unoccupied? / Yes / No
Are all opening windows and external doors protected by the alarm or sensor? / Yes / No
Do you have electronic gates? / Yes / No
Is there an electric fence around the total perimeter of the property? / Yes / No
Is the house situated in a high security complex? (24hr guards - Electric Fencing) / Yes / No
Are there any additional security features not mentioned above?
Are there any factors nor mentioned above that may adversely affect the security risk of the residence?
BUILDING ONLY:
Do you require power surge cover? (Only on Building Insurance) R10 000 R20 000 R30 000 R40 000 R50 000
Do you require extended subsidence and landslip cover? (only on Building Insurance) Separate questionnaire to be completed
UNSPECIFIED ITEMS (Items worn on person e.g. clothes, gym bag, wallet, handbag) No electronics or jewelry
R5000 - R25 pm / Yes / No
R7000 - R37,50 pm / Yes / No
R10 000 - R50 pm / Yes / No
SPECIFIED ITEMS - ITEMS THAT IS TAKEN OUT OF THE HOUSE AND YOU WANT TO INSURE MORE SPECIFICALLY
SPECIFIED ITEMS : CAMERA - CELLPHONES / Serial Number / Sum Insured
1
2
3
PLEASE SUPPLY VALUATION CERTIFICATE FOR JEWELERRY
PERSONAL ACCIDENT / Yes / No
Name
ID Number
Death: R
Perm Dis: R
Temp Dis: R
Medical: R
Motor / Vehicle 1 / Vehicle 2
Has this vehicle been purchased through : Dealership Privately
Type of Cover / Comprehensive / Comprehensive
Third Party, Fire & Theft / Third Party, Fire & Theft
Third Party Only / Third Party Only
Use of Vehicle / Strictly private / Strictly private
Business use / Business use
Professional use / Professional use
Social (Inc to work & back) / Social (Inc to work & back)
ARE BUSINESS GOODS CARRIED? / Yes No / Yes No
If yes, state nature of goods
Make and Model
Year of Registration
Retail Value
Color
Registration Number
Engine Number
Vin Number
Is the vehicle modified or converted?
(If Yes, supply detail)
Average km's travelled per month
Imported Vehicle / Yes No / Yes No
Soft Top / Yes No / Yes No
Anti-Hijack / Yes No / Yes No
Alarm or Transporter Key / Yes No / Yes No
Factory fitted Immobilizer / Yes No / Yes No
Tracking device / Yes No / Yes No
Make of Tracking device
Registered Owner of Vehicle
Finance house of vehicle
Address during day (Security)
Address during night (Security)
REGULAR DRIVER - NB
Name and Surname
ID Number
Year of Driver License
Occupation
Relationship to Insured
Marital Status
Defense Driving Course
WILL ANYBODY ELSE BE DRIVING THE VEHICLE?
Name and Surname
ID Number
Year of Driver License
Occupation
Relationship to Insured
Marital Status
Defense Driving Course
OPTIONAL INSURANCE ON VECHICLES (ADDITIONAL PREMIUM)
Car Hire (Theft & Accident) 30 Days from R63 pm & 60 days R97pm / Yes No / Yes No
Exs buy back - No exs on any motor claims / Yes No / Yes No
Top-Up Insurance/Credit Shortfall / Yes No / Yes No
Tyre Insurance R3000 per tyre (Cover for Potholes and tyre damages) / Yes No / Yes No
AFTER MARKET EXTRAS ON VEHICLE / MAKE / VALUE
Radio
Sunroof
Mags & Wheels
Other Items
CARAVANS/TRAILERS
Make & Model
Year
Value
Registration Number
MOTOR CYCLES
Make & Model
Year
Value
Registration Number
Use / Private / Business
TYPE OF MOTOR CYCLE
Road Bike
Cruiser
Off Road
Quad
Personal Liability - R3 000 000 Automatically added to your policy
THE FOLLOWING PARTS IS APPLICABLE ON ALL SECTIONS OF COVER
Any Claims or losses the past three years (whether insured or not)
YEAR / DESCRIPTION / AMOUNT
PREVIOUS / CURRENT INSURANCE DETAIL / POLICY NUMBER / PERIOD
Signature of Insured / Date
Signed on behalf of the Company / Date