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INSURED

Region:

Name:

Address:

Cell No:

Tel No:

Fax No:

Email:

ID No:

VAT No:

LOSS/DAMAGE OCCURANCE

Date and Time of loss/damage:

When was loss/damage discovered?:

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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Name:

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ID No/Company Reg No:

Address:

Policy No:

* Please note that your policy will be sent through once email is received.

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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:

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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