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INSURED
Region:
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Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
Address:
Cell No:
Tel No:
Fax No:
Email:
ID No:
VAT No:
LOSS/DAMAGE OCCURANCE
Date and Time of loss/damage:
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04
05
06
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08
09
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12
13
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15
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17
18
19
20
21
22
23
00
05
10
15
20
25
30
35
40
45
50
55
When was loss/damage discovered?:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
00
05
10
15
20
25
30
35
40
45
50
55
LOSS/DAMAGE PLACE
Place where loss/damage occurred:
(a)Were premises occupied?:
(b)By Whom?:
If not occupied when last occupied?:
Purpose of occupation: e.g. Office Space
CAUSE OF LOSS/DAMAGE
Describe fully how the loss or damage occurred stating how (if applicable) entry was gained to the premises:
If loss/damage caused by another party give name and address:
PREVIOUS LOSS/DAMAGE
Have you previously suffered a loss/damage?:
If so, give details:
If insured, provide name of insurer:
POLICE
Police Station:
Reference Number:
Date Reported:
OTHER INTEREST
Has any other party an interest in the insured property, e.g. Credit agreement:
If so, give name and interest:
OTHER INSURANCE
Is there any other insurance covering this loss?:
If so, give name of insurers:
VALUE
Estimated total of all the property, insured under the policy:
When last valued?:
PAYMENT METHOD
Name of bank:
Account Holder:
Branch Code:
Type of account:
Account number:
DECLARATION
I/We solemnly declare that I/we have suffered loss of or damage to the property enumerated and that the said property was in/my possession immediately prior to the said loss/damage which occurred in the circumstances described above.
Signature:
QTY
Description of Property
Date Acquired
Purchase Price
Amount Claimed
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Item:
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Domestic Forms
Change of Address Questionnaire
Domestic New Business Proposal
Bidvest Platinum Domestic Proposal
Household Inventory Form
Mechanical Report
Medical Report
Bidvest Cycle Guard New Business Proposal
Domestic Uninsured Risks
Bidvest Personal New Business Proposal
Domestic Motorcycle New Business Proposal
Subsidence and Landslip Questionnaire
CHANGE OF ADDRESS / ADDITIONAL PREMISES FORM
GENERAL INFORMATION
Region:
Select a Region
Kwa-Zulu Natal
Gauteng
Eastern Cape
Western Cape
Name:
New Address:
Cell No:
Tel No:
Fax No:
Email:
Policy Ref:
Occupation:
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):
If YES, is the roof protected by a lightning conductor approved by the SABS?:
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?
Is the residence undergoing alterations?
Is the residence situated in a newly developed area?
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?
Will the residence be left unoccupied during working hours?
Will the residence be left unoccupied for more than a total of 60 days a year?
Will the residence be hired or let out or used as a commune?
If YES, please give details:
PLEASE TELL US
Are all the opening windows (including louvres) burglar barred?
Are the fixed windows burglar barred?
Are the external sliding doors fitted with security gates or frame mounted key-operated locking bolts?
Are other external doors fitted with security gates?
Is the perimeter of the property walled/fenced?
Are there full-time security guards on your property?
Is your home protected by a fully operational burglar alarm?
Does it extend to the garage and/or all other outbuildings?
If YES, please state the name of installer:
(DOCUMENTARY PROOF FROM INSTALLER REQUIRED)
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?
Does it incorporate an immediate siren?
Is the system automatic? (it does not necessitate any action from the residents to activate the alarm system in the event of a burglary)?
Are you a pensioner 65 or older?
Does the dwelling comply with the requirements in the High Security Living Declaration?
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 electrified 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 electrified 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:
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