Compendium Insurance Group (Pty) Ltd.

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CHANGE OF ADDRESS / ADDITIONAL PREMISES FORM

GENERAL INFORMATION
Id Number :
Name
New Postal Address:
Telephone (H):
Telephone (W) :
Cell. :
Email Address:
Policy Ref:

Address of property to be insured (If more than one property is to be insured, complete an additional questionnaire)

How long have you lived at the address given?

Years: Months

Approximate age of the dwelling?

Years: Months

Is the roof of your house made of thatch? (Please tick one)

Yes No

If YES, is the roof protected by a lightning conductor approved by the SABS?

Yes No

WHAT TYPE OF HOME DO YOU HAVE?

House	Flat above ground floor	Holiday cottage or flat
Townhouse	Ground floor flat	Cluster House
Retirement village	Semi-Detached	Complex
Duplex	Granny Flat	Maisonette
Simplex	Other

SITUATION

Is the residence situated on a smallholding, plot or farm?

Yes No

Is the residence undergoing alterations?

Yes No

Is the residence situated in a newly developed area?

Yes No

Are there any of the following within approximately 1km radius of the residence?

Informal settlements	Vacant ground	Park
Railway lines	Minedumps	Sports fields
Golf course	Shops / Café	Railway station
Taxi rank	Highway	Building construction

OCCUPANCY

Will the residence be left unoccupied within the next 30 days?	Yes No
Will the residence be left unoccupied during working hours?	Yes No
Will the residence be left unoccupied for more than a total of 60 days a year?	Yes No
Will the residence be hired or let out or used as a commune?	Yes No

If YES, please give details:

PLEASE TELL US

Are all the opening windows (including louvres) burglar barred?	Yes No
Are the fi xed windows burglar barred?	Yes No
Are the external sliding doors fi tted with security gates or frame mounted key-operated locking bolts?	Na Yes No
Are other external doors fi tted with security gates?	Yes No
Is the perimeter of the property walled/fenced?	Yes No
Are there full-time security guards on your property?	Yes No
Is your home protected by a fully operational burglar alatm?	Yes No
Does it extend to the garage	Yes No
and/or all other outbuildings?	Yes No
If YES, please state the name of installer	Yes No
(DOCUMENTARY PROOF FROM INSTALLER R EQUIRED)	Yes No
Is it linked to a control centre with armed response which will respond in person at the premises in the event of the alarm being activated?	Yes No
Does it incorporate an immediate siren?	Yes No
Is the system automatic? (it does not necessitate any action from the residents to activate the alarm system in the event of a burglary)?	Yes No
Are you a pensioner 65 or older?	Yes No
Does the dwelling comply with the requirements in the High Security Living Declaration?	Yes No

HIGH SECURITY LIVING QUESTIONNAIRE (tick one only)

I confirm that I live in the following premises where all major building construction has been completed:

1. SECURE COMPLEX where

the property is fully walled with an electrifi ed fence

there is 24hr manned security with supervised entry and exit from the property

2. RETIREMENT VILLAGE where
• the property is fully walled with an electrifi ed fence
• there is 24hr manned security with supervised entry and exit from the property

DECLARATION

DECLARATION - High Security Living Questionnaire I declare that the dwelling indicated above complies with the security
requirements shown. It is understood that the insurer has the right to repudiate liability for loss or damage arising out of theft or
attempted theft if at the time of loss or damages the above security requirements have not been complied with.

Signature: