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Insurance Proposal
Please fill out this form and we will get in touch with you shortly
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id
date time
Business Name
Contact Person
Email
ID No
Contact No
Fax No
Physical Address
Code
Description of Business
Number of Years in Operation
Has the company or its owner ever been placed under provisional liquidation, legal administration etc
No
Yes
Has the business or its owner ever traded under a different name
No
Yes
Are there more vehicles in the fleet than those quoted on here? If Yes please provide details
No
Yes
Details
Has any insurer ever cancelled, imposed special conditions or refused to renew your policy?
No
Yes
Your Current or Last Insurer?
Please provide a detailed claims history for the last 5 years
2010
2011
2012
2013
2014
Is the claims ratio for the last 2 years greater than 80%
No
Yes
Is the claims ratio for the last 2 years greater than 60%
No
Yes
Fleet operational radius
Other countries outside SA
Please declare any other Material Facts
Fleet list (make, model, year, value)
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Excess Reducer, Loss of Use
Agreed Values, Goods in Transit
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