TECHNICAL UNDERWRITERS PLANT ALL RISKS (PAR) INSURANCE PROPOSAL

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					29 WATERFORD OFFICE PARK WATERFORD DRIVE FOURWAYS

TECHNICAL UNDERW RITERS
INSURANCE YOU CAN TRUST FROM PEOPLE YOU CAN COUNT ON

P.O. BOX 520 BANBURY 2164

TELEPHONE: (011) 658-1156 FACSIMILE: (011) 658-1175 WEBSITE: www.consort.co.za

PLANT ALL RISKS (PAR) INSURANCE PROPOSAL (ANNUALLY RENEWABLE CONTRACTS) Broker / Agent Information
Broker Name Branch Consort Agency Number Broker Contact Person : : : :

Proposer Information
Type of business Postal Address : :

Contact Person Telephone Number Fax Number Cell phone Number E – Mail Address Proposer’s VAT Number

: : : : : :

Proposer’s Company Registration Number: Holding Company Details :

CONSORT TECHNICAL UNDERWRITING MANAGERS (PTY) LTD REGISTRATION NUMBER: 99/03909/07 FINANCIAL SERVICES PROVIDER NUMBER: 2273 DIRECTORS: P. A. CHARLTON G. B. CHARLTON A. J. CHARLTON R. J. SYMMONDS

Driver / operator Information
Will the plant be operated by: Owner only : Specific operators : General operators : Casual / part time operators: YES YES YES YES NO NO NO NO

Are operators previous employment records, including accident records checked? YES NO

Are operators subjected to full medical examinations prior to and during employment? YES Main geographic area of operation: Detail any precautions in place to avoid losses arising out of theft, hi-jack or accident: NO

Are anti-theft tracking devices fitted? YES Is any plant fitted with tachographs or other management devices? YES How is the plant protected when not in use? Whilst on site Whilst at Proposer’s premises : : NO NO

Plant Information
Make & Model Year Reg. or Vin no. New replacement value Market value

*Please attach full schedule of plant Please note that total loss claims will be settled on Market value

CONSORT TECHNICAL UNDERWRITING MANAGERS (PTY) LTD REGISTRATION NUMBER: 99/03909/07 FINANCIAL SERVICES PROVIDER NUMBER: 2273 DIRECTORS: P. A. CHARLTON G. B. CHARLTON A. J. CHARLTON R. J. SYMMONDS

Will the insured plant be hired out? YES If yes, please give details : NO

Will the insurance be required for plant hired-in? YES If yes, please give estimated annual hire fee expenditure : R Please indicate the type of plant hired-in: Mobile cranes Mobile construction plant Non-mobile plant / equipment Do you require SASRIA : : : : YES YES YES YES NO NO NO NO NO

Previous Insurance
Name of previous insurer :

Has any insurer declined your proposal / cancelled or declined to renew your policy? If yes, please provide details:

Please give details of all losses during the past three years: Date of loss Plant Description of loss Gross damage

*Please attach full list of occurrences

Disclosure
We hereby declare that the statements made by us in this Questionnaire and Proposal are, to the best of our knowledge and belief, complete and true, and we hereby agree that this information forms the basis and is part of any policy issued in connection with the above risk. It is agreed that the Company is liable in accordance with the terms of the Policy only. The Company undertakes to treat this information in strict confidence.

Signature

:

Date

:

CONSORT TECHNICAL UNDERWRITING MANAGERS (PTY) LTD REGISTRATION NUMBER: 99/03909/07 FINANCIAL SERVICES PROVIDER NUMBER: 2273 DIRECTORS: P. A. CHARLTON G. B. CHARLTON A. J. CHARLTON R. J. SYMMONDS


				
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Description: TECHNICAL UNDERWRITERS PLANT ALL RISKS (PAR) INSURANCE PROPOSAL