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Application form - 1 Underwritten on behalf of Renasa Insurance

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Application form - 1 Underwritten on behalf of Renasa Insurance Powered By Docstoc
					         PO Box 945 Umkomaas 4170.
                             Tel: 039 976 1642 Fax: 0866 275 988
                 E-mail info@ibg-uma.co.za Website: www.ibg-uma.co.za


         Underwritten on behalf of Renasa Insurance Company (Pty) Ltd

Contingency Business Overhead and Disability Contingency Income Replacer Application:

Broker name:       _________________________________________Broker code:____________

Broker House: _________________________________________

F.S.P. No:         _________________________________________

Insured Surname :______________________First name:________________________

ID

Occupation:___________________________________________________________________

Business Name:__________________________________________________________________

Owner Registration no/ID:________________________________________________________

Owner Address:_________________________________________________________________

_________________________Postal Code:___________ (If Different to Employer)


Employment: Part time:               Full time:

State percentage of work per day that consists of (Total percentage be 100%)

Administration           %                    Cover Option         6       12     24             R

Manual                   %

Supervisor               %

Travel                   %

Contact details:
Phone Office:                                             Fax Office:
Phone Home:                                               Fax Home:
Cell:                                                    E-mail addr:_______________________________




                 IBG Underwriting Managers (Pty) Ltd Reg no: 2007/019619/07 VAT No: 4740251188       1
                                 An Authorised Financial Services Provider FSB No: 36515
                                       Directors: I.B. Down, G. McNeil, M.J. Haken
Debit Order Details:
                                                                                    Dd         mm   ccyy
Name of Bank                                                  Debit Order Date
                                                              (1st to 15th)
Account Type                                                  Branch

Account No
Bank code
Account Holder                                                          Signature of account holder


                                                                     ______________________________
Medical Questionnaire

1.      Do you smoke or have you smoked during the 12 months?                            Yes        No

2.      Do you or have you during the past 3 years participated or do you intend in the future to
        participate in any hazardous occupations? I.e. Flying, gliding, diving, professional sports,
        mining, motor sports security force, explosive handler, taxi industry, security industry,
        protection services, micro lender. industry or any other occupation with increased risk to
        accident or risk to health.                                           Yes       No

        If yes please state occupation:___________________________________________________

3.      Has an application for, medical, disability or dread Disease Insurance
        (e.g heart attack) on your life ever been declined, post or withdrawn
        or accepted on special terms or at special rates?                                 Yes       No

4.      Have you had any disease, injury or disorder, which necessitated
        treatment or bed rest for more than 6 days or prevented you from
        practicing your occupation for more than a month in the past 3 years?             Yes       No


5.      Have you received any medication or other treatment uninterruptedly
        or longer than 6 days within the past 5 years.?                                   Yes       No



        If you have answered yes to any of the above questions, please give details:

        Question no:         Date of occurrence:      Describe claim or condition




Name and address of usual Medical Practitioner:

        Dr: ______________________________                    Initials: __________


               IBG Underwriting Managers (Pty) Ltd Reg no: 2007/019619/07 VAT No: 4740251188               2
                               An Authorised Financial Services Provider FSB No: 36515
                                     Directors: I.B. Down, G. McNeil, M.J. Haken
        Address:__________________________                     E-mail: _____________________

                 ___________________________                   Cell:    _____________________

        Code:    ___________________________                   Tel:     _______________________




Terms and Conditions

The applicant accepts the terms and conditions of the Master Policy attached hereto.
The applicant understands the scope of the cover provided in terms of the attached quotation and
the explanation accompanying this quotation.
The applicant understands the cover is renewable on a monthly basis; however as the term of the
contract is monthly, failure to meet contributions after a claim has been intimated could jeopardise
settlement of the claim unless premiums continue to be paid until the deemed annual review date of
the policy.

I, the undersigned, hereby accept the above term and conditions

Signed at_____________________on this____________day of ________, 200__



__________________
Signature of Applicant.




                IBG Underwriting Managers (Pty) Ltd Reg no: 2007/019619/07 VAT No: 4740251188     3
                                An Authorised Financial Services Provider FSB No: 36515
                                      Directors: I.B. Down, G. McNeil, M.J. Haken

				
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