Quotation - Business
 
 
  Please complete the fields below:
     
  Broker:
  Insured:
  Business / Occupation:
  Risk Address:
  Postal Address:
  Other Locations:
     
   
  Provide details of all claims experienced in the last three years
   
  2009:
     
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
     
  2010:
     
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
     
  2011:
     
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
     
  2012:
     
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
  Description / Remark
  Type of claim
  Amount
     
  General:
   
 
   
   
  Section 1. Fire
   
  Please complete the fields below:
     
  Premises Address
  Type Roof Construction
  Type Wall Construction
  Sum to be insured
  Premises Address 2
  Type Roof Construction
  Type Wall Construction
  Sum to be insured
     
   
  Section 2. Building Combined
   
  Please complete the fields below:
     
  Premises Address
  Type Roof Construction
  Type Wall Construction
  Sum to be insured
  Premises Address 2
  Type Roof Construction
  Type Wall Construction
  Sum to be insured
     
   
  Section 3. Office Contents
   
  Please complete the fields below:
     
  Description 1
  Contents
  Documents
  Liability for Documents
  Sum to be insured
  Description 2
  Contents
  Documents
  Liability for Documents
  Sum to be insured
     
   
  Section 4. Business Interruption
   
  Please complete the fields below:
     
  Premises: 1
  Item 1 Gross Profit
  Item 2 Gross Rentals
  Item 3 Revenue
  Item 4 Additional Increased Cost of Working
  Item 5 Wages ( % For Weeks)
  Item 6 Fines & Penalties
  Premises: 2
  Item 1 Gross Profit
  Item 2 Gross Rentals
  Item 3 Revenue
  Item 4 Additional Increased Cost of Working
  Item 5 Wages ( % For Weeks)
  Item 6 Fines & Penalties
     
   
  Section 6. Theft
   
  Please complete the fields below:
     
  PREMISES 1 Sum to be insured
  PREMISES 2 Sum to be insured
     
   
  Section 6. Money
   
  Please complete the fields below:
     
  PREMISES 1 Sum to be insured
  PREMISES 2 Sum to be insured
     
   
  Section 8. Glass
   
  Please complete the fields below:
     
  PREMISES 1 Sum to be insured
  PREMISES 2 Sum to be insured
     
   
  Section 9. Fidelity Guarantee
   
  Please complete the fields below:
     
  Number of employees
  Named and or position basis
  Named and or position basis
  Named and or position basis
     
   
  Section 11. Business All Risks
   
  Please complete the fields below:
     
  Description
  Serial number
  Sum to be insured
  Description
  Serial number
  Sum to be insured
  Description
  Serial number
  Sum to be insured
  Description
  Serial number
  Sum to be insured
     
   
  Section 12. Accidental Damage
   
  Please complete the fields below:
     
  PREMISES 1 Sum to be insured
  PREMISES 2 Sum to be insured
     
   
  Section 13. Public Liability Limit of Indemnity - R1500000.00 ADDITIONAL COVER R20 000 000-00- INDEMNITY GENERAL LIABILITY TOP UP (R960-00 PER ANNUM) per premises - R 20,000,000.00
   
  Please complete the fields below:
     
  Number of premises covered
     
   
  Section14. Motor
   
  Please complete the fields below:
     
  Make & Model
  Year
  Type of Cover
  Business use
  Sum Insured
  Make & Model
  Year
  Type of Cover
  Business use
  Sum Insured
  Make & Model
  Year
  Type of Cover
  Business use
  Sum Insured
  Make & Model
  Year
  Type of Cover
  Business use
  Sum Insured
     
   
  Section 15. Electronic Equipment
   
  Please complete the fields below:
     
  Description
  Serial number
  Sum to be insured
  Description
  Serial number
  Sum to be insured
  Description
  Serial number
  Sum to be insured
  Description
  Serial number
  Sum to be insured
     
  Who referred you to our business: