Offer to Purchase Boat Form

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Offer to Purchase Boat Form Powered By Docstoc
					                                               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 repres ent the New Replacement Value otherwise A verage 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 S UM INSURED (A+ B+C+ D+E) R                                                                    .../Page 2...

                                Authorised Financial Serv ice 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 (Privat e 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 purpos es 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 que stions - 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 mont h 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 w ithheld, and I undertake to exercis e all ordinary and reasonable precautions for the safety of the property, and I further declare that if suc h
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 betw een 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 reserve s the right to decline this Insurance

                                        Authorised Financial Serv ice Provider – Licence No. 4430

Description: Offer to Purchase Boat Form document sample