UMA Motor Aansoekvorm by gyvwpsjkko

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									UMA MOTOR ONLY PROPOSAL FORM
                            INLIGTING - NUWE KLIËNTE INFORMATION - NEW CLIENTS

Naam van kliënt
Name of client

Posadres
Postal
address
Poskode                                                    ID No
Postal Code                                                ID Nr

Telefoon Nr.                                        Faks Nr.                            Selfoon
Telephone No.                                       Fax No.                             Cellphone

E-pos adres
E-mail address

Risiko Adres
Risk Address

Beroep                                                                                  Taal
Occupation                                                                              Language

 1.   Is u nou of was u ooit verseker? Indien wel, meld naam van die
      versekeraar en polisnommer. Are you now or have you ever been
      insured? if so, state name of insurer and policy number.                            Nr / No

 2.   Het enige versekeraar ooit/Has any insurer ever:
         a.    U aansoek geweier?                                                                   JA \ NEE
               Declined your proposal?                                                              YES \ NO

         b.    U polis gekanselleer of geweier om dit te hernu                                      JA \ NEE
               Cancelled or refuse to renew your policy?                                            YES \ NO

         c.    Spesiale voorwaardes of verhoogde premies of bybetalings ingestel                    JA \ NEE
               Imposed special conditions or increased premiums or excesses?                        YES \ NO

      Indien bevestigend, verstrek volledige
      besonderhede/If affirmative,
      give full details
  Aanvangsdatum van dekking                                                        Pensionares
    Inception date of cover                                                         Pensioner


Naam van Agent / Makelaar
Name of Agent / Broker




                                                                       Page 1
LETTER OF APPOINTMENT                                                                     Date:

We, ___________________________________________, (hereinafter “the Client”) , hereby appoint UMA Insurance Brokers
(hereinafter “UMA” ) as our Insurance intermediary with immediate effect, and please co-operate fully with them in providing any
information they may request.

We, the Client, confirm that we have been made aware of and hereby agree to the following:-


        1.   Our duties of Disclosure and of Good Faith, and in particular our obligation to disclose to insurers any “material”

             circumstance which may in any way affect the risk or the underwriters decision to insure it, and at what price.

        2.   Our duty to notify circumstances that could give rise to a claim as soon as possible, and certainly within any time
             period stipulated in the relevant Policy.

        3.   Although UMA only utilize reputable insurers for the placement of business, they cannot accept responsibility for the
             future solvency of these insurers nor for their ability or otherwise to pay claims.

        4.   UMA currently have Professional Indemnity and Fidelity Guarantee insurance coverage in place.
             Notwithstanding this, UMA hereby limit there Liability for any loss or damage that the Client may suffer arising directly
             or indirectly from UMA’s performance or non-performance whether arising out of negligence or any other cause , to a
             maximum amount of R50 Million in all, and furthermore UMA will not under any circumstances be liable to the Client
             for any indirect, consequential or economic loss nor for punitive damages.



        5.   The necessity for us to pay the premium upon presentation of invoices, and that failure to do so may invalidate our
             insurance coverage.

        6.   UMA undertake to act at all times in accordance with the SAFSIA Code of Conduct as well as in terms of the FAIS
             Act No.37 of 2002, which means that UMA will conduct business in good faith and with integrity, and will provide the
             Client with appropriate short-term insurance related advice, and intermediary services relating to the placement of
             the Clients’ insurance coverage with the selected insurer, and assistance with the annual renewal of insurance
             contracts, and advice and services relating to Claims. We, the Client, understand the content of this Letter of
             Appointment and we hereby accept these terms and conditions as the basis of the appointment of UMA as our
             insurance intermediary as confirmed by our signature hereunder.



                       Signed at __________________________ on this _____day of _________ 2_____


                      For and on behalf of __________________________________________(the Client)


                _______________________________________                                  _____________________
                      CLIENT SIGNATURE                                                                WITNESS


                             Who warrants that he/she is duly authorized to act on behalf of the Client


                      Signed at _________________________on this_____day of ____________2______

                ________________________________________                                 _____________________
                   INTERMEDIARY SIGNATURE                                                              WITNESS


                                Who warrants that he/she is duly authorized to act on behalf of UMA




                                                                        Page 2
DECLARATION               (You must complete and sign this section)

      Have you or any member of your firm had any application for insurance been declined or insurance cancelled, or renewal
 1.
      refused or not invited, or had special conditions imposed? Y/N……………….
      If yes, provide details

      ……………………………………………………………………………………………………………………………………….

      Have you or any member of your firm been involved in any civil or criminal litigation in the past 3 years?
 2.
      Y/N……………………
      If yes, provide details

      ……………………………………………………………………………………………………………………………………….

      Have you or any member of your firm ever made an agreement with creditors regarding debt, or been sequestrated, or
 3.
      been declared insolvent? Y/N………………………………..
      If yes, provide details

      ……………………………………………………………………………………………………………………………………….

 4.   Have you or any member of your firm had any civil judgements recorded against you? Y/N……….……………………
      If yes, provide full details regarding every individual judgement

      ……………………………………………………………………………………………………………………………………….

 5.   Have you or any member of your firm had any civil judgements recorded against you? Y/N……..……………………..
      If yes, provide full details regarding every individual judgement

      ……………………………………………………………………………………………………………………………………….

 6.   Do you keep a complete set of books showing a true and accurate record of business transacted? Y/N…………….
      If yes, provide details

      ……………………………………………………………………………………………………………………………………….

 7.   Give details of All losses suffered in the past 3 years (whether insured or not)

          Type of loss (Fire, Motor, Accident, Burglary ect..)                                Year            Loss Amount




I/We declare that all particulars and answers in this proposal and application are true and complete in every respect,
and that no material fact has been suppressed or withheld. I/We further declare that if these statements and
particulars are the writing of any person other than myself/ourselves, such person shall be deemed to have been
my/our Agent for the purpose. I/We agree that this declaration and the details given shall be the basis of the contract
between myself/ourselves and the Insurance Company (referred to as the company).

I/We further agree to accept a policy subject to the usual conditions prescribed by the Company and endorsed on
their policy, and to pay premium there under. I/We undertake to exercise all ordinary and reasonable precautions for
the safety of the property for which insurance is proposed.


                                                  ……………………………………………..
                                                              Capacity




                                                                          Page 3
DEBIET ORDER MAGTIGING / DEBIT ORDER AUTHORITY




                                   PREMIE BETAALWYSE / PREMIUM PAYMENT METHOD

MAANDELIKSE DEBIET ORDER / MONTHLY DEBIT ORDER                                                   JA \ NEE    YES \ NO

REKENING TIPE / ACCOUNT TYPE                SPAAR \ SAVINGS             TRANSMISSIE \ TRANSMISSION   TJEK \ CHEQUE

NAAM VAN REKENING HOUER / NAME OF ACCOUNT HOLDER

NAAM VAN BANK / NAME OF BANK

TAK & TAK KODE / BRANCH & BRANCH CODE

REKENING NOMMER / ACCOUNT NUMBER

DEBIET ORDER DATUM / DEBIT ORDER DATE                               1            7       10



GETEKEN DEUR REKENING HOUER / SIGNED BY ACCOUNT HOLDER : ____________________________________



 I HEREBY GIVE UMA UNDERWRITING CONSULTANTS PERMISSION TO DEDUCT MY INSURANCE PREMIUM MONTHLY
                                                FROM MY BANK ACCOUNT.


                                                          MOTOR

MAAK EN MODEL                                                                        JAAR
MAKE AND MODEL                                                                       YEAR

TIPE DEKKING                                              WAARDE                               PREMIE
TYPE OF COVER                                             VALUE                                PREMIUM

REG                                              ENJ NO                                                     GEB
NO                                               ENG NO                                                     NCB

ONDERSTEL
VIN NO

SEKURITEITS STELSEL                                                         LISENSIE EERSTE UITREIKING DATUM
SECURITY SYSTEM                                                             LICENSE FIRST ISSUE DATE

OPSIONELE DEKKING / OPTIONAL COVER                                                             Koste / Cost Yes    R
Motor Huur / Car Hire                                                                            60.00
LDV Huur / LDV Hire                                                                              60.00
Afkoop van Bybetaling / Excess Waiver                                                            60.00
Assist / Bystand                                                                                 20.00
                                          Perlk / Limit   R 10 000                               30.00
Krediettekort / Credit shortfall          Perlk / Limit   R 20 000                               50.00
Motor Radio / Motor Radio               Beskrywing / Description:                              @ 10% rate

Voertuig op enige manier gemodifiseer. Vehicle in anyway modified?

Voertuig 'n Kode 3 / Vehicle code 3 ?




                                                                        Page 4
Voertuig Sekuriteitsvereistes / Vehicle Security Requirements
R 0 - R 150 000 VSS of SAIA Immobiliseerder vlak 3 / VSS or SAIA Approved Immobilizer level 3
R 150 000 - R 200 000 VSS of SAIA vlak 4 Immobiliseerder / VSS or SAIA level 4 Immobilizer
R 200 000 + VSS of SAIA Voertuigopsporingstelsel / VSS or SAIS Vehicle Tracking Device
Nie-nakoming van enige van bogenoemde vereistes ten opsigte van Diefstal en of Kaping sal geen dekking tot gevolg hê.
Non compliance of the above security requirements will result in No Teft and Hijack cover.
EERSTE BEDRAE BETAALBAAR / EXCESS STRUCTURE
1. Basiese Bybetalings / Basic Excess: 7.5% van eis Minimum R 2500.00 / 7.5% of claim Minimum R2500.00
2. Windskerm Bybetaling / Windscreen Excess: 20% van eis Minimum R 500.00 / 20% van claim Minimum R500.00
3. Radio & Toerusting Bybetaling / Audio & Equipment Excess : 10% van eis Minimum R 500 / 10% of excess Minimum R500
4. Verlies van Sleutels Bybetaling / Loss of Keys Excess: 10% van eis Minimum R 250.00 / 10% of claim Minimum R250.00
5. Diefstal & Kaping Bybetaling / Theft & Hijack Excess: 10% van eis Minimum R 2500.00 / 10% of claim Minimum R2500.00
6. Tweede Eis in 1 Jaar / Second Claim in 1 year: Addisionele R 2500.00 / Addisional R2500.00
7. Eis binne 6 Maande van Aanvang / Claim within 6 months of Inception: Addisionele 5% van eis Minimum R2500.00 /
    Addisional 5% of claim Minimum R2500.00
8. Derde Party Bybetaling indien geen eie skade nie / Third Party Claim if no own damage: R 1500.00
9. Onder 25 & Lisensie korter as 5 jaar / Under 25 & license not longer than 5 years: 5% van eis Minimum R2000.00 /
   5% of claim Minimum R2000.00
Hiermee verklaar ek, die versekerde dat my voertuig aan die sekuriteits vereistes soos bo genoem voldoen en indien my voertuig
nie aan die vereistes voldoen nie dat die nodige sekuriteits stelsel binne 7 dae van aanvangsdatum geinstalleer sal word.
Hiermee verstaan ek ook dat na die 7dae daar geen Diefstal / Kaping dekking toegestaan sal word nie indien die bewys van
installasie gelewer kan word.
With this signature I the insured declare that my vehicle comply with the above security requirements. If not, I declare that the
necessary security system will be installed within 7days of inception of policy. I understand after 7days Theft / Hijack cover will
only be given if proof of installation can be provided.



                                                                                                Handtekening / Signature




                                                                       Page 5

								
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