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P O Box 13445

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					                                                                      P O Box 13445
                                                               HATFIELD PRETORIA 0028
                                                                   Block A, West Wing
                                                          Lynnwood Corporate Park Ground Floor
                                                              Cnr Sanlam & Alkantrant Road
                                                                LYNNWOOD GLEN 0033
                                                                   Tel : (012) 348 9337
                                                                   Fax : (012) 361 3427


                                                             MOTOR VEHICLE INSURANCE PROPOSAL
                                    Before completing this proposal kindly read the synopsis on the back of the proposal

Name of Proposer :                                                                                                 ID number :

Postal Address        :                                                                                            Postal Code :

Occupation          :                                                                                             Tel No (W) :

Club/Membership No :                                                                                              Tel No (H) :

                                                            PARTICULARS OF VEHICLE TO BE INSURED
  Make and Full Description of             Registration           Chassis and      Year of     Cubic Capacity of                          Valuators Present value
           Vehicle                           number             Engine Number    manufacture        Engine                            including accessories and parts




PLEASE BE ADVISED THERE IS NO COVER FOR SOUND EQUIPMENT UNLESS FULL MAKE , MODEL AND VALUE IS SPECIFIED

Period : From                                                                         To                                         31 st June

1) State address or place at which the vehicle is usually garaged or parked :

       (i) locked in a garage                    (ii) vehicle port                          (iii) in open private property                       (iv) in open roadway

a) Overnight :

b) During the day :

2) Is the vehicle fitted with an anti – theft device? If “yes” please state make and type of device (siren, immobiliser etc.)

3) Please indicate the cover required:

Comprehensive                                                        Comprehensive (Laid up)                                     (refer synopsis)

4) Will this vehicle be used on a daily basis?                  Yes / No

5) Will the vehicle be used solely for Social Domestic Pleasure Business and Professional purposes EXCLUDING use described in (a) to (f) below?
   (refer synopsis). State Yes / No                              . If “No” tick against appropriate additional Use.

a) For hiring or the carriage of passengers for hire or reward                             (d) For rallies reliability trials racing speed or other
  (Other than for weddings and or special occasions)                                           contests (for exceptions see Synopsis)

b) For commercial travelling                                                               (e) In connection with the Motor trade

c) For driving instruction reward                                                           (f) In connection with any Insurance Business

6) Have there been any accidents or losses (whether resulting in a claim or not) during the past three years in connection with any motor vehicle or motorcycle
   owned or driven by you or used by you? Answer “YES” or “NO”                if “YES” give details below:

                           Total No of accidents or losses in connection with a motor vehicle                             Amount Paid                Estimated
Year                                           OWNED or DRIVEN by you                                                                             Amount to be paid
      State date of issue of driving licence
7)
      Do you, or does any other person who to you knowledge will drive, suffer from defective vision or hearing or from any physical or mental infirmity?
8)    If so give details



      Have you, or has any other person who to your knowledge will drive, been convicted or paid an admission of guilt, fine during the past five years
9)    for any offence in connection with the driving of any motor vehicle or is any prosecution pending? If so give details:



      a) Are you the owner of the vehicle?                                      (b) Is the vehicle registered in your name?
10)
      c) If not registered in your name state name and address of owner and of the person in whose name the vehicle is registered


      PLEASE NOTE NO COVER CAN BE GIVEN FOR COMPANY OWNED / REGISTERED VEHICLES

      Has the vehicle been modified in any way to increase the performance or is any such modification intended? If so give details
11)


      Has any Insurer in respect of yourself, or any other person who will drive, ever declined a proposal or required special terms or conditions or
12)   increased premiums or cancelled or refused to renew a policy?                                    If so give details



      Are you now or have you been insured in respect of any motor vehicle?                                                        If so give details
13)


      Will any vehicle to be insured be driven by any person other than yourself or family or club member? (Refer synopsis)
14)
      If “Yes” state:
            i)          Name of Person (s)

             ii)        Age (s)

             iii)       Date(s) driving licence(s) obtained

             iv)        How long has he or she been driving?

             v)         Whether he or she has been involved in any motor accident?

      It is obligatory for the vehicle to be insured to be fitted with a fire extinguisher

      Photographs must either accompany proposal or must be forwarded within 30 days of inception of cover and must be signed and
      verified by the club valuator


      DECLARATION:
      I/We hereby declare that all the above statements and particulars are true, correct and complete and contain all information known to
      me/us affecting the risk to be insured and that this and any other written statement made by me/us or on my/our behalf for the purpose
      of the proposed insurance shall be the basis of and incorporated in the contract between me/us and the Company shall be promissory.
      I/We undertake that the vehicle to be insured shall not be driven by any person who to my knowledge has been refused any motor
      vehicle insurance or continuance thereof. I/We further agree to accept insurance on the terms and conditions set forth in the
      Company’s policy.


      Date                                                          Signature of Proposer

                    COVER ONLY AVAILABLE TO FULLY PAID UP MEMBERS OF A ONE MARQUE CAR CLUB AFFILIATED TO SAMCA
                         NO LIABILITY IS UNDERTAKEN UNTIL THIS PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY
Synopsis of cover as detailed:

Interest                :              All privately owed motor vehicles belonging to any paid up member of a one marque car club


Cover                   :                   a)    Full comprehensive Motor cover, including windscreen on an indemnity basis (Market Value) in respect of
                                                  all vehicles less than 10 years old from date of first registration.

                                            b)    Full comprehensive Motor cover, including windscreen on an indemnity basis (Agreed Value) in respect of
                                                  all vehicles older than 10 years old from date of first registration.

                                            c)    Comprehensive laid up – no road risk – vehicle under restoration

Maximum Indemnity                      Maximum indemnity of R150 000 any one vehicle

                                       Vehicles in excess of R50 000 are subject to a premium adjustment

Third Party Liability                  R2 500 000 third party liability any one accident or occurrence

                                       R1 000 000 in respect of passenger liability any one accident or occurrence

                                       R 50 000 in respect of Passenger Liability in open sports cars any one accident or occurrence

                                 1)           PLEASE NOTE IT IS IMPORTANT TO READ THE POLICY WORDING IN CONJUNCTION WITH THE
                                                                                CERTIFICATE

Requirements                     2)    Four colour photographs , front, side and back, of the vehicle signed and dated by the club valuator to accompany all
                                       proposals

                                 3)    All valuations must be signed and rubber stamped by the signatories of the said club, ie the chairman of the center or
                                       valuator.
                                 4)
                                       Driving restricted to the insured and members of his family and or other club members.

                                       Vehicle use includes social, domestic, pleasure and traveling to and from permanent place of employment, official
                                       club meetings including Samca Gymkhana's where Samca licences and Indemnities are required and rallies excluding
                                       racing, speed trials and non club events.

                                 5)    NB!! NO COVER IS PROVIDED FOR ANY GYMKHANA OR SPEED EVENT TACKING PLACE ON A RACE
                                       TRACK WHERE THERE IS MORE THAN ONE VEHICLE PARTICIPATING.
                                 6)
                                       No radio cover will be provided unless specifically requested.
                                 7)
                                       ONLY ON RECEIPT OF 1&2 of the above will cover be granted
                                 8)
                                       All vehicles are to be valued every 18 months, these are to be rubber stamped by the club
                                 9)
                                       All vehicles rebuilt or altered during the period of insurance will require a new valuation and new photographs

                                 10)   The valuations to be based on the standard valuation procedure as detailed on the proposal forms obtainable from
                                       Thebe Insurance Brokers

                                       In the event of the valuation of the insured vehicle not being updated during the previous 18 months by an authorised
Claims Procedure                       Club Committee member, the company will only be liable under section one (loss or damage ) of the policy of the
                                       reasonable market value of the vehicle at the time of the loss or damage, provided the maximum amount payable
                                       does not exceed the limit of indemnity as stated in the schedule.

                                       All claim forms are to be obtained from the brokers Thebe Risk & Benefit Group Pretoria
                                       On receipt thereof assessors will be appointed. All disputes will be arbitrated by the club
                                       A panel of suitable qualified assessors have been appointed to agree quantum on claims

Valuations                             Valuations of the vehicles must be updated every 18 months or the policy will revert to market value
                                      SAMCA
                            INSURANCE ASSESSMENT FORM
                                 TO BE COMPLETED BY APPROVED CLUB VALUATOR
Insureds Name:                                                       Date:

Club Membership No:                                                  Make of Vehicle:
                                                                     Type :                                      Year:
Club:
                                                                     Colour:
Club Centre                                                          Vehicle registration



                      MINT (5)                EXCL (4)               GOOD (3)                  FAIR (2)               POOR (1)


TYRES & WHEELS

BODY

INTERIOR

ENGINE

MECHANICALS

                      Total ÷ 5                                              Assessed By: (name)

                      Vehicle assessed as:                                                  Value R
TYRES & WHEELS        To qualify as mint - Tyres must be new, correct type for year of vehicle and all five the same make
                      Wheels must have no blemishes and be the correct size and type
                      To qualify as excellent - Tyres must be as above but only slightly worn tyres and slight blemishes
                      on the wheels
                      To qualify as good - Tyres must have better than average tread ad good sidewalls and wheels in better than
                      average condition
                      Retreads in good condition will only qualify as fair, as well roadworthy tyres not of the same type and make on
                      vehicle
                      A vehicle with poor tyres may not be value as anything but laid up
BODY                  To qualify as mint - Perfect fit, no ripples, no blemishes on paint
                      To qualify as excellent - Minor irregularities on otherwise mint vehicle
                      To qualify as good - No visible dents of consequence, better than average paint and as with mint and excellent
                      NO MODS TO ANY BODY PANELS CONTRARY TO FACTORY SPECS
INTERIOR              To qualify as mint - Must be trimmed in correct type of material and correct pattern with no visible wearing or
                      sagging
                      To qualify as excellent - Totally original interiors still with no serious visible wear
                      To qualify as good – Re trimmed interiors in wrong material to correct pattern and slightly worn original
ENGINE                To qualify as mint - Must have perfect paintwork and no trace of overspray, oil or grease on wiring harness
COMPARTMENT           To qualify as excellent - Totally original but very clean or recently restored but not quite mint or original
                      To qualify as good – obviously well maintained and clean
MECHANICALS           Use your discretion after checking underside of vehicle, listening to engine and checking oil pressure, exhaust and
                      gearbox in motion as to how vehicle sounds and feels
WINDSCREEN            Please confirm windscreen free from cracks or chips
PHOTOGRAPHS           Please enclose four signed colour photographs of each vehicle (front, rear, left and right side)

                      NOTE: THIS VALUATION MUST BE UPDATED EVERY 18 MONTHS

				
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