CIB Commercial Proposal Formcdr

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CIB Commercial Proposal Formcdr Powered By Docstoc
					PROPOSAL FORM
INSURANCE SOLUTIONS

DETAILS
Broker PRI Number Name of Proposer Full Trading Name of Company Company Registration Number/ I.D. Number of Proposer (if not company) Company VAT Registration Number Postal Address Physical Address Inception Date

Code Description of Business Contact Person Telephone Number Cellular Number Fax Number E-mail Address

Code

THE FOLLOWING SECTION MUST BE COMPLETED (Please Tick)
POLICY SECTIONS APPLICABLE POLICY SECTIONS (Cont) APPLICABLE POLICY SECTIONS (Cont) APPLICABLE

1. COMMERCIAL

1. COMMERCIAL

1. COMMERCIAL

! Fire ! Buildings Combined ! Office Contents ! Business Interruption ! Accounts Receivable ! Theft ! Money
2. CIB HOSPITALITY

! Glass ! Fidelity ! Goods in Transit ! Business All Risk ! Accidental Damage ! Public Liability ! Employers’ Liability
3. CIB AGRI

! Stated Benefits ! Group Personal Accident ! Motor Section ! Electronic Equipment ! Motor Traders Internal ! Motor Traders External

4. CIB ENGINEERING

! Plant All Risks
5. CIB MARINE 6. CIB BUILDINGS

! Contractors All Risks

SIGN

GENERAL
1. Has any insurer ever declined a proposal of yours, cancelled any policy (or any section thereof) of yours, imposed any special conditions, refused to renew any policy (or section thereof) of yours, or refused to continue with any insurance of yours? If YES, please give full particulars: YES NO

2. Have any of the directors / partners / shareholders in your company ever been declared insolvent or had any judgements taken against them? If YES, please give full particulars:

YES

NO

3. Have you had any previous losses / claims in the last 5 years?

YES

NO

PREVIOUS INSURERS’ DETAILS
Company: Policy No.:

TYPE OF LOSS / CLAIM

YEAR

AMOUNT

INSURER

PERSONAL LIABILITY
This is automatically added to your policy Limit of Liability is R9 000 000 (nine million rand)

SIGN

METHOD OF PREMIUM PAYMENT
Please indicate below with an “X”, the method of premium payment required. Yearly in cash OR Per monthly debit order to be drawn against a cheque account a transmission account Preferred date that debit order is to be presented on the 1st of every month on the 7th of every month

DEBIT ORDER INFORMATION AND AUTHORISATION
Account Holder (Name of Account Holder) Cheque / Transmission Account No. (Client identification number) Institution / Branch Identification No. (e.g. Banks clearing number) Name of Bank (Name of Institution)

I authorise CIB Insurance Solutions to draw on my account (wherever it may be) at the above-mentioned institution, the amount of the monthly premium (which includes VAT) payable. Signature of Account Holder

DECLARATION
I / We hereby declare that all the statements and particulars in this proposal are true and correct and contain all the information known to me for the purpose of the proposed insurance which shall be the basis of an incorporated in the contract between myself / ourselves and CIB Insurance Solutions. I / We declare that if such statements and particulars are in the handwriting of any person other that myself / ourselves such person shall be regarded as having been my / our agent for the purpose of filling in same. I / We by our signature hereto irrevocably authorise and consent to CIB Insurance Solutions or its nominated agents performing credit checks as they deem fit. Date Day / Month / Year

Authorised Financial Services Provider

SIGN

MOTOR DETAILS
VEHICLE 1
Description of Vehicle

TO BE COMPLETED FOR UNDERWRITING PURPOSES

INSURANCE SOLUTIONS

VEHICLE 2
Description of Vehicle

Values of extras with description

Values of extras with description

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

VEHICLE 3
Description of Vehicle

VEHICLE 4
Description of Vehicle

Values of extras with description

Values of extras with description

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

VEHICLE 5
Description of Vehicle

VEHICLE 6
Description of Vehicle

Values of extras with description

Values of extras with description

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

SIGN

MOTOR DETAILS
VEHICLE 7
Description of Vehicle

TO BE COMPLETED FOR UNDERWRITING PURPOSES

INSURANCE SOLUTIONS

VEHICLE 8
Description of Vehicle

Values of extras with description

Values of extras with description

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

VEHICLE 9
Description of Vehicle

VEHICLE 10
Description of Vehicle

Values of extras with description

Values of extras with description

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

VEHICLE 11
Description of Vehicle

VEHICLE 12
Description of Vehicle

Values of extras with description

Values of extras with description

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

Year Model Registration No. Registered Owner Address where kept at night (if not behind locked gates or in a locked garage)

SIGN

ELECTRONICS & ALL RISK DETAILS
TO BE COMPLETED FOR UNDERWRITING PURPOSES
INSURANCE SOLUTIONS

DESCRIPTION OF ELECTRONICS
MAKE MODEL SERIAL NO. IF POSSIBLE REPLACEMENT VALUE

PERSONAL LIABILITY
This is automatically added to your policy Limit of Liability is R9 000 000 (nine million rand)

DESCRIPTION OF ALL RISKS
MAKE MODEL SERIAL NO. IF POSSIBLE REPLACEMENT VALUE

PERSONAL LIABILITY
This is automatically added to your policy Limit of Liability is R9 000 000 (nine million rand)

SIGN


				
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posted:12/19/2009
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Description: CIB Commercial Proposal Formcdr