; Offer to Purchase Boat Form Motorboat Proposal Form TO BE COMPLETED IN FULL Name
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Offer to Purchase Boat Form Motorboat Proposal Form TO BE COMPLETED IN FULL Name


Offer to Purchase Boat Form document sample

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  • pg 1
									                                               Motorboat Proposal Form
                                               TO BE COMPLETED IN FULL

Name of Proposer: _____________________________________________ I.D. No. _________________________
Occupation: __________________________________________________________________________________
Postal Address: ________________________________________________________________ Code: __________
Physical Address: ______________________________________________________________________ Code:
Telephone: (H) ____________________ (B) __________________________ Cell: _________________________
Fax: ____________________________________ E-mail ______________________________________________
Are you the sole owner of the vessel?: YES         NO         If NO, give details: ____________________________
All sums insured if not older than 4 years must represent the New Replacement Value otherwise Average will
A. Particulars Of Hull                                      Boat’s
 Type or Make       Length       Year       Material of         Built By          Registration #   Sum Insured
     of Boat                     Built         Hull
        (A Survey Report form needs to accompany this proposal for Boats or Motors older than 10 years.)
B. Particulars of Motors
                    Manufacturer           H.P.              Year              Serial #          Sum Insured
Inboard                                                                                        R
Outboard 1                                                                                             R
Outboard 2                                                                                             R
Propeller            Make                Pitch/Material                           SUB TOTAL            R
Standard with
C. Particulas of Trailer
       Built By                 Year Built                       Registration #                       Sum Insured
Specify All equipment you require to be insured on the All Risk Facility with values of each item.
 D. Particulars of Personal, Water skiing & Fishing Equipment e.g. Water Toys, Stainless Steel Propellers,
                                                   Fishing Rods
                                Description                                              Age       Sum Insured
1.                                                                                                      R
2.                                                                                                      R
3.                                                                                                      R
(Supply seperate list for additional items.)                                        SUB TOTAL           R

E. Particulars of Special Electronic Equipment e.g. Radio, Fishfinder, GPS
                      Description & Serial Number                                           Age            Sum Insured
1.                                                                                                      R
2.                                                                                                      R
                                                                                    SUB TOTAL           R

TOTAL SUM INSURED (A+B+C+D+E) R                                                                       .../Page 2...

                                 Authorised Financial Service Provider – Licence No. 4430
Please send through a copy of the “Offer to Purchase”the “Tax Invoice” and a colour photograph for our records
Page 2
1. Date Purchased: _____________________________
2. From whom (Private or Dealer): _________________
3. Price paid: ___________________________ Inception Date of this policy :
4. Is the craft subject to finance, and if so with whom andphone number? _________________________________
5. Will the craft be used for your private pleasure purposes only? YES                               NO
    If no, state the purpose for which it will be used? __________________________________________________
6. How many years experience have you had operating a vessel of this type? _____________________________
7. Have you previously claimed on a marine insurance policy? YES                                NO
8. Have you had any insurance declined, cancelled or renewed on restricted terms?                              YES         NO
9. Have you or any person using your craft been convicted of a crime involving dishonesty of any kind (i.e. fraud,
theft, smuggling, robbery, arson etc.)? YES      NO
If answered Yes to any of the questions - Q7, Q8 and or Q9 , please give full details on a seperate page.
10. Will the vessel be used for Surf Launching? YES                          NO          (If Yes – Attach SAMSA & Skippers
11. Where is your vessel kept when not in use?
12.What security measures are in place when the vessel is not in use? If afloat on moorings – please state the
name of the Marina and whether they are professionaly laid & maintained & secured

13. Will the vessel be used outside RSA, state where ?
SASRIA (Political Riot & Strike cover) is automatically in the policy.
 (Premiums can be paid monthly through a Bank Cheque or Savings Account and or Annually. The debit orders will
come off your account on the 1st working day of every month with EPIC as a reference on your bank statement).
  Name of Bank/Building                                      Branch
 Type of Account                                                           Account No

 Branch Code                                                               (Bank current accounts only–see top right hand corner of

 Name of Account Holder                                 Signature
Club Care Fee – There is an automatic R 20 per month payable per month

NOTE: By signing this form you appoint Club Marine Insurance as your broker for the risks as laid out by this

I hereby declare that the above particulars and answers are true and complete in every respect, and that no material fact has been suppressed
or withheld, and I undertake to exercise all ordinary and reasonable precautions for the safety of the property, and I further declare that if such
statements and particulars are in the writing of any person other than myself, such person shall be deemed to have been my agent for the
purpose, and I agree that this declaration and the answers given above shall be the basis of the contract between me and the Company, and I
further agree to accept a Policy subject to the ususal conditions prescribed by the Company and endorsed on their Policy, and to pay the
premium thereunder when called upon to do so.
Signing this form does not bind the Proposer to effect this insurance, but it is agreed that this form shall be the basis of the contract should a
policy be issued.

Dated: __________________________ Signature of Proposer: ________________________________________
                      The Company reserves the right to decline this Insurance

                                        Authorised Financial Service Provider – Licence No. 4430

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