Motor Theft Claim Form by monkey6

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                                   INSURANCE INFORMATION DECLARATION

1                            Postal Address

                             Physical Address

                             Suburb
                             City/Town
                             Province
                             Country/State
                             Postal Code
                             Country

1 Developments/changes anticipated
   1.1 Expansions


    1.2 New products, services or processes


    1.3 Other (incl. Acquisitions & Disposals)



                                       Valuation Basis Key
                   NRV=New Replacement Value; MV- Market Value AV- Agreed Value

2 ASSETS

Provision must be made for all assets owned, leased or for which you are or hold yourself responsible to arrange
insurance. Allowance should be made for any purchase, developments, acquisitions or disposals.

Insured values must represent estimated new replacement value(NRV) including debris removal, site clearance
and professional fees, special foundations and tenants improvements for all assets.

If a valuation basis other than NRV is required (market value MV, agreed value AV), please identify the item
clearly. Obsolete plant or equipment, computers etc. may require special insurance treatment.

Where replacement assets are required to be imported, please allow for duties and exchange rate fluctuations.

                                                                                                                          Cover   Sums
                                                                                                                                  Insured
2.1 Buildings (incl. Sidings, reserviors, boundary walls, roads, bridges, Gardens,
landscaping etc.)
       2.1.1 Owned                                                                                                        NRV
       2.1.2 Leased/rented (your responsibility for insurance) Lessor’s Full Name:                                        NRV

       2.1.3 Moth-balled                                                                                                  AV
       2.1.4 Obsolete/redundant                                                                                           AV

2.2 Fixtures and fittings                                                                                                 NRV
2.3 Office Contents (excluding electronic equipment)                                                                      NRV
2.4 Stock                                                                                            NRV

           2.4.1 Raw materials in the open                                                           NRV
           2.4.2 Other raw materials                                                                 NRV
           2.4.3 Finished goods                                                                      NRV

           2.4.4     Consignment Stocks                                                              NRV

           2.4.5     All other stocks                                                                NRV

For stocks stored off-site, please provide the following details:
       Description:                                                                                  NRV
       Location:                                                                                     NRV
       Physical Address:                                                                             NRV
   2.5 Plant And Machinery (owned or leased. Incl. Process Control equipment,
          furnace linings, special foundations etc.)
       2.5.1 Key                                                                                     NRV
       2.5.2 Obsolete/redundant                                                                      AV
       2.5.3 Other                                                                                   NRV
   2.6 Patterns, moulds or dies

         2.6.1 Owned                                                                                 NRV
         2.6.2 Third party for which you are responsible                                             NRV
     2.7 Cranes (mobile/tower/other)                                                                 NRV
     2.8 Forklifts (incl. Pallet and reach trucks)                                                   NRV
     2.9 Electronic equipment (excluding process control equipment)
           2.9.1 Owned                                                                               NRV
           2.9.2 Leased                                                                              NRV
           2.9.3 Software (excluding off-the-shelf products)                                         NRV
    2.10 Other assets (fuel, spares, consumables, watercraft, locomotives etc)                       NRV
Total Assets

      2.10           Other property (not stock) stored off-site and included in above values

                      Description
                      Location
                      Physical Address

      2.1.2        Uninsured property (List items, Values not included above)\



3         RIOT AND TERRORISM

          Describe, if applicable, extent of current riot and terrorism cover in force.
          ………………………………………………………………………………………………..
          ………………………………………………………………………………………………..
          ………………………………………………………………………………………………..
          ………………………………………………………………………………………………..
          ………………………………………………………………………………………………..

4         BUSINESS INTERRUPTION


    4.1     Calculation of Budgeted Gross Profit
            Net Revenue after disbursements/Turnover 12 months
            Plus Closing Stock (if applicable)                                                 (a) ______________
            Sub-Total
          LESS uninsured working expenses (those which will vary in direct
          proportion to a reduction in turnover).

          Purchase (net of discounts recieved)
          Packing Materials
          Discounts Allowed
          Bad Debts
          Commissions Paid (Optional)
          Royalties
          Railage and Shipping Out
          Water, Power, Fuel (the variable element)
          Rebates
          Any other – please specify




          Plus Opening Stock if applicable




          Sub-Total                                                                 (b) ________________
              Annual Insurable Gross Profit (a-b) + (VAT)
              Rate of Gross Profit      Gross Profit x 100                         (c) ________________
                                          Turnover                                      ________________
             Net Profit before Tax and interest (+VAT)                              (d) ________________
             Standing charges (Gross Profit LESS Net Profit) (c) – (d)

Projection for
    Gross Profit                      _______________                   ___________________
    Net Profit                        _______________                   ___________________
    Standing Charges                  _______________                   ___________________


5         MAXIMUM INDEMNITY LIMITS (maximum amount of any one loss)
               5.1 Property (excl. cash) in transit
               5.2 Air (doestic)
               5.3 Rail                                                                       _____________
               5.4 Road                                                                       _____________

    5.1    Cash in Transit
                 5.21 Maximum value of wages payable per week                                  _____________
                 5.22 Maximum value of wages payable per week in December                      _____________

    5.2    Fidelity- no. of employees whose primary responsibility is:
                  5.31 Cheque signing and cash handling                                        _____________
                  5.32 Stock handling                                                          _____________

    5.3    Third Party Computer Fraud                                                          ____________
                 5.1 Maximum value of any                                                      ____________

6         MACHINERY BREAKDOWN                                                                   Sum Insured

    6.1    Blanket basis                                                                       ____________
          6.1.1         New Replacement cost                                                   ____________
    6.2              Specified basis

                  Item No              Description of critical Plant/Machinery           New Replacement Cost
              1
              2
              3
              4
              5



7     LIABILITIES
       7.1 Projected Turnover/Revenue Analysis (excluding inter-company sales) for the periods indicated in
       respect of the following activities:
              Item              Description of critical           Current Year               Next Year
                                   Plant/Machinery
           7.1.1        Revenue for services provided.
           7.1.2        Turnover from the sale of products
           7.1.3        Turnover for the design and building
                        of construction contracts
           7.1.4        Fees from professional consultancy
                        advice or services.
           7.1.5        Other turnover (specify activity)
           TOTAL

          7.2 Projected Sales/Turnover/Fees derived from other group companies



              7.3 Product recall (i.e. the cost of retrieving product from the market)             Yes/No
              7.3.1 Do you have a crisis management plan for recalling product?
              7.3.2 What indemnity limit would be adequate to cover recall costs?
              7.3.3 Do you supply products to a third party for incorporation into                 Yes/No
                    another product?


          7.4 If fees have been declared in 7.1.4 please indicate where the following professional advice, design or
              service is provided.
                     Professional Service               No. of Professionals         Are all professionals qualified
                                                                                                by exam?



          7.5 Direct EXPORTS to USA/Canada (i.e. first party only, not via a third party)
                           Product Exported                    Est. Annual Turnover per Product


          7.6 Analysis of Turnover/Revenue by country/region
                              Country/Region                                       Projected Turnover
              RSA
              USA/Canada
              UK and Europe (EC)
              Europe (non-ECC)
              South America
              Africa (excluding RSA)
              Australia
              Elsewhere (specify)
                                                  Total

7.7 If the Company provides advice, design or consultancy services for or in connection with prototypes
    or innovative products, please provide details.




7.8 Information relating to USA/Canada sales offices, manufacturing or other operations

            Company/Name                        Physical address                    Product Details


7.9 Please give details of any subsidiary or joint venture that has been sold or ceased trading. Each of
these are separate insured’s whose past activities must be declared to insurers.




7.10 If full rights of recourse are wavered against sub-contractors, consultants and products suppliers,
     please provide details:



7.11 Airstrip/ helipad operation/ ownership
     Do you own, operate or maintain an airstrip or                           Yes/No
     helipad, Including those belonging to others?
     If so please supply details


7.12 Aviation Products
     Do you manufacture or supply products or
     services for the aviation industry?

7.13 If you offer a haulage/transport contractor with
     responsibility for goods in your care, custody
     and control, please state Turnover derived
     from this activity.

7.15 Do you charter vessels or aircraft?
                                                                              Yes/No

7.16 Do you have trading conditions?
                                                                              Yes/No
     Are they universally imposed?
     If not to which customers and why?                                       Yes/No


     Do you have any agreements with
     customers/suppliers/landlords or other service                           Yes/No
     providers allow a hold harmless’ indemnity?

7.17 Do you produce, manufacture or deal with
     chemicals?                                                               Yes/No
      If yes, please detail.
       7.1.9 Wageroll (Expendature)

       7.19.1 Clerical, directors and managers
       7.19.2 Other Manual workers
       7.19.3 Sales Representatives
       7.19.4 Other

7             MOTOR FLEET (company vehicles only)


       8.1 Fleet Strength
               Private Vehicles are sedans, station wagons, safari vans, LDV’s and mini-buses designed to
               carry max. 12 passengers (excluding the driver).

               Commercial Vehicles are vehicles designed for the carriage of goods.

               Special Type Vehicles are vehicles specified designed/adapted for business use and which are
               restricted to the business premises.
               Include mobile cranes.

                     Type                             No. Of Units                     Total Market Value
       Private vehicles
       Commercial vehicles
       Special types
       Trailers
       Buses
       Motor cycles
       Other (specify)
       Total



             8.2 Maximum value of all vehicles on the business premises at any one time       R


             8.3 For special vehicle insurance please provide the following details:

                 Year                      Model                      Reg. No.               Market Value




9 Plant and Crane Hire

       9.1 Estimated annual hire fees of mobile cranes
       9.2 Estimated annual hire fees of other mobile plant
       9.3 Are cranes with a rated capacity of 50 tons ever used?                                  Yes/No
       9.4 Will cranes be used for tandem or multiple lifts?                                       Yes/No

10. Construction Risks (Principal Controlled)

    Capex and plant improvements budgeted including installation
    or movement of new or used plant and machinery and all other
    construction (excl. Work performed as a contractor for others)
    10.1 In respect of work awarded to CONTRACTORS, estimated CAPEX
            10.1.1 ‘New’ Works
            10.1.2 Repositioning, refurbishing of existing/used plant & machinery
    10.2 Work undertaken IN-HOUSE but only for ‘New’ Works
    10.3 Estimated maximum value of any one contract or project incl.
         Free issue of materials and relocation of materials

11 Construction Risks (Asset Programme)

  CAPEX and plant improvements budgeted for IN-HOUSE work comprising repositioning, upgrading or
  refurbishing of existing plant, machinery or facilities

    11.1 Estimated CAPEX
    11.2 Estimated maximum value of any one contract or project incl.
         Free issue of materials and relocation of materials
    11.3 Budgeted maintenance

12 Stated Benefits (IF APPLICABLE)

      Annual earnings are defined as the amount of remuneration paid in money or kind including overtime,
      commission and bonus payments, cost of living, food and quarter allowances but not including traveling,
      subsistence or other allowances of a reimbursive nature or casual or ex-gratia payments.

    12.1 Estimated annual earnings
    12.2 Maximum limit required in respect of any one accident or series of accidents
         arising from one cause

								
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