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PersonalTakafulAgreementApplicationtoparticipate
Importantnotes1.PleaseprintinBLOCKLETTERS.2. Noagreementisinforceuntilwehavereceivedthefullycompletedandsignedapplicationformandconfirmedcover.Ifwedeclineyourapplication,wewillnotifyyouoryourbrokerimmediately.
3.Please(!)theapplicableblocksforyes/noanswers.4.Ifinsufficientspaceisavailableontheformpleaseprovideanswersonthelastpageunder“AdditionalInformation/Comments”.
BrokerDetailsAgency/broker
Agencynumber
CoverRequiredCoverisavailableforthefollowingclasses.Please(!)theclassesyourequirecoveronandcompletetherelevantsectionsintheapplicationform.
NoapplicationisrequiredforSasriaasitisautomaticallyincluded(N.B.SasriadoesnotformpartofyourPersonalTakafulAgreement)
Section
Buildings(Home) MotorCycles PersonalAccident
HouseholdContents Caravan/Trailers MotorPersonalAccident
SpecificItems(AllRisks) PersonalLegalResponsibility LegalCosts
PersonalComputerEquipment ExtendedPersonalLegalResponsibility Watercraft MotorVehicles
PersonalDetailsFirstname(s)
Surname
Identitynumber
Dateofbirth
Postaladdress
Postalcode
Physicaladdress
Postalcode
Participant’soccupationorbusiness
Contactdetails
Telephonenumber(work)
Telephonenumber(home)
Telephonenumber(cell)
Faxnumber
EmailaddressZurichInsuranceCompanySouthAfricaLimited|15MarshallStreet,Ferreirasdorp,Johannesburg,2001|POBox61489,Marshalltown,2107|TelephoneNo.+27113709111|www.zurich.co.zaRegistrationNo.1965/006764/06|ZurichisanauthorisedFinancialServicesProviderNo.17703 1of18
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Co-participant
Firstname(s)
Surname
Identitynumber
Dateofbirth
Postaladdress
Postalcode
Co-participant’soccupationorbusiness
Contactdetails
Telephonenumber(work)
Telephonenumber(home)
Telephonenumber(cell)
Faxnumber
Emailaddress
Coverrequired
Effectivedate
Languagepreference English Afrikaans
GeneralInformation
Previouscover? Yes No
Ifyes,givefulldetails,i.e.nameofinsurer,policynumber,inceptionandcancellationdate(s)Hasanyinsurerevercancelled,declinedorrefusedtorenewyourcoverorimposedspecialterms? Yes No
Ifyes,givefulldetailsGivedetailsofalllossesorclaimssufferedinthelast3years(whethercoveredornot)
Typeofloss(fire,motor,accident,burglary,etc.) Year Amountpaid(approximate)Doyouintendgoingonholidaywithinthenexttwomonths? Yes No
Ifyes,givefulldetails
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Willthepremisesbeleftvacantforlongerthan60daysinanycalendaryear? Yes No
Ifyes,givefulldetails
Isthepremisesoccupiedduringtheday? Yes No
Ifyes,bywhom?Isanypartofthepremisesusedforbusinesspurposes? Yes No
Ifyes,givefulldetails
Isthepropertyisolated,e.g.onaplotoragriculturalholding(s)? Yes No
Ifyes,thePlotQuestionnaireistobecompleted
Pensionerinformation(tickappropriatebox)
Notapensioner Pensionerover55
Employedover50 Pensionerinaretirementvillage
Willthepremisesbeunoccupiedduringtheyear(tickappropriatebox)
Morethan60days 90days 120days 150days
180days 210days 240days 270days
300days
Buildings(Home)andHouseholdContentsSectionsInrespectofpropertytobecoveredpleasestate
Details Premises1 Premises2
Physicaladdress
Postalcode Postalcode
Construction Walls:Standardornon-standard
Roof:Standardornon-standardIfthatch,theQuestionnaireistobecompleted
Dwellingtype(pleasespecify) Clusterhome
Privatedwellinghome
Farmdwelling
Flat/apartment
Retirementvillage1
Simplex/duplex
Holidayhome
Townhouse
Parkhome
1Asecurecomplexorretirementvillagemeansacomplexwithhighperimeterwallswitheitherrazorcoilwireoranelectricfenceontopoftheperimeterwalls.Thecomplexmusteitherhavea24-hourstaffedsecuritygateoraccessmustbecontrolledbyan intercom,remotecontrolorregistrationatthegate.
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Details Premises1 Premises2
Occupiedbyyouas Owner Owner
Tenant Tenant
Securityprotectionsrequirements
Burglarbarsonallopeningwindows
Securitygatesonallopeningdoors
Alarmwitharmedresponse
Yes No Yes No Yes No Yes No Yes No Yes No
Ifyes,isamaintenancecontractinplace? Yes No Yes No
Nameofsecurityserviceprovider
Securecomplex/retirementvillage Yes No Yes No
Buildings(Home)Section
Building(Home)isdefinedastheprivateresidence,allgaragesandoutbuildings;brick,concreteortardriveways,pathsorpatios;walls,gatesandfences(otherthanhedges);tennisandsquashcourts;structureorfabricofswimmingpools,saunaorspabathsandboreholepumpssituatedattheaddressstatedintheschedule.
Financenoted(mortgagee)
Details Premises1 Premises2
Sumcovered R R
Optionalcover Maximumamountofcover
Accidentaldamagenototherwisecovered Yes No ROptional-MinimumR5,000;MaximumR100,000
Breakdownoffixedmachinery Yes No R
Optional-MinimumR5,000;MaximumR100,000
Additionalpowersurge(optionaltolimitedcover) Yes No R
Optional-MinimumR5,000;MaximumR100,000
Fullsubsidenceandlandslip Yes No R
(Geotechnicalreportrequired)
HouseholdContentsSectionThecompletionoftheinventoryformonthelastpageofthisapplicationwillassistinestablishingcorrectcurrentreplacementcostofcontents.
Details Premises1 Premises2
Sumcovered R R
Areyouentitledtoaclaimfreediscount? Yes No Yes No
Ifyes,namethecompanyandattachproofofdiscount
Businessfromhome Yes No Yes No
Limitedto35%ofsumcoveredlimitedtoR50,000
Optionalcover Maximumamountofcover
Accidentaldamagenototherwisecovered Yes No R
Optional-MinimumR5,000;MaximumR100,000
Electricalandmechanicalbreakdown Yes No R
Optional-MinimumR5,000;Maximum:R100,000
Additionalpowersurge(optionaltolimitedcover) Yes No ROptional-MinimumR5,000;MaximumR100,000
Subsidenceandlandslip Yes No R
(Geotechnicalreportrequired)
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SpecificItems(AllRisks)Section
Description Maximumamountofcover
Unspecified R
Specifieditems R
1. R
2. R
3. R
4. R
Notes
1.Attachvaluationcertificatesforitemssuchasspecifiedjewellery(exceedingR5,000)andincludephotographsifavailable.2.Whereapplicable,includeserialnumbersofspecifieditems.3.Describeitemsasfullyandaccuratelyaspossible.
PersonalComputerEquipmentSectionAddressofcomputerequipmentDescription Maximumamountofcover
Specifieditems R
1. R
2. R
3. R
4. R
Computersoftware Yes No R
Optionalcover
Reinstatementofdata(limitedtolaptopsanddesktops) Yes No R
MotorVehicleSectionDetails Vehicle1 Vehicle2
Yearofmanufacture
Makeandmodel
Mead&McGroutherCode
Maximumamountofcover(retailvalue) R R
Agreedvalue R R(specificvehiclecriteriaifagreed)
Typeofcover Comprehensive Comprehensive
Thirdparty,fireandtheft Thirdparty,fireandtheft
Thirdpartyonly Thirdpartyonly
Comprehensiveexcludingtheft Comprehensiveexcludingtheft
Classofuse A B C A B C
A.Privateand limitedprofessionalandbusinessuse:Social,domestic,pleasureandprofessionaluse, includingtravel toandfromyour homeandpermanentplaceofwork,studyorprofession.B.Private,professionalandfullbusinessuse:Social,domestic,pleasure,professionalandfullbusinessuse, includingtravel toandfrom yourhomeandpermanentplaceofwork,studyorprofession.
C.Privateuseonly:Social,domestic,pleasurepurposesonly.
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Details Vehicle1 Vehicle2
Registrationnumber
Vehicleidentificationnumber
Enginenumber
Financehouse
Claimfreegroup
Vehiclecolour
Overnightparking Carport Carport
Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking
Securityprotection Yes No Alarm Alarm
Gearlock Gearlock Immobiliser Immobiliser Trackingdevice Trackingdevice Recoveryidentification Recoveryidentification
Trackingdevice Yes NoIfyes,pleasegivethefollowingdetailsandprovidecertificate
Trackingdevicemakeandmodel
Trackingdeviceserialnumber
Trackingdeviceinstallationdate
Registeredownerdetails
Nameandsurname
Identitynumber
Principaldriverdetails
Nameandsurname
Identitynumber
Gender Male Female Male FemaleMaritalstatus Cohabitant Cohabitant
Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow
Additionaldriverterms
Additionaldrivers Yes No
Name,surnameandidentitynumber
1.
2.
3.
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Details Vehicle1 Vehicle2
Optionalcover Maximumamountofcover Maximumamountofcover
Vehicleaccessories(postmanufacturing)
Covered Yes No Yes No
Itemsdescription
Towbar Yes No R R
Leatherseats Yes No R R
Bluetooth Yes No R R
Creditshortfall Yes No R R(Comprehensivecoveronly)
Additionallocksandkeys Yes No R R
Excesswaiver Yes No R R
Voluntaryexcess Yes No R R
Additionalwreckageremoval Yes No R R
Additionalthirdpartyliability Yes No R R(MaximumlimituptoR10,000,000)
Optionalcoverextension
Carhire
Covered Yes No Days 30 45 Days 30 45
MotorCycleSectionDetails Cycle1 Cycle2
Yearofmanufacture
Makeandmodel
Mead&McGroutherCode
Maximumamountofcover(retailvalue) R RTypeofcover Comprehensive Comprehensive
Thirdparty,fireandtheft Thirdparty,fireandtheft
Thirdpartyonly Thirdpartyonly
Classofuse A B C A B C
A.Privateand limitedprofessionalandbusinessuse:Social,domestic,pleasureandprofessionaluse, includingtravel toandfromyour homeandpermanentplaceofwork,studyorprofession.B.Private,professionalandfullbusinessuse:Social,domestic,pleasure,professionalandfullbusinessuse, includingtravel toandfrom yourhomeandpermanentplaceofwork,studyorprofession.
C.Privateuseonly:Social,domestic,pleasurepurposesonly.
Enginecapacity
Importedormodified Yes No Yes No
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Details Cycle1 Cycle2
Registrationnumber
Vehicleidentificationnumber
Enginenumber
Financehouse
Claimfreegroup
Overnightparking Carport Carport
Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking
Registeredownerdetails
Nameandsurname
Identitynumber
Principaldriverdetails
Nameandsurname
Identitynumber
Gender Male Female Male Female
Maritalstatus Cohabitant Cohabitant
Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow
Additionaldriverterms
Additionaldrivers Yes No
Name,surnameandidentitynumber
1.
2.
3.
4.
5.
Optionalcover Maximumamountofcover Maximumamountofcover
Creditshortfall Yes No R R(Comprehensivecoveronly)
Additionallocksandkeys Yes No R R
Additionalwreckageremoval Yes No R R
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QuadsandOffRoadSection
Details Cycle1 Cycle2
Yearofmanufacture
Makeandmodel
Maximumamountofcover(retailvalue) R R
Typeofcover Comprehensive ComprehensiveClassofuse C C
C.Privateuseonly:Social,domestic,pleasurepurposesonly.
Enginecapacity
Importedormodified Yes No Yes No
Registrationnumber
Vehicleidentificationnumber
Enginenumber
Financialhouse
Overnightparking Carport Carport
Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking
Registeredownerdetails
Nameandsurname
Identitynumber
Principaldriverdetails
Nameandsurname
Identitynumber
Gender Male Female Male Female
Maritalstatus Cohabitant Cohabitant
Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow
Additionaldriverterms
Additionaldrivers Yes No Yes No
Name,surnameandidentitynumber
1.
2.
3.
4.
5.
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MotorisedRideOnEquipmentsuchasGolfcarts,SedgewayandRideOnLawnmowersSection
Details 1 2
Yearofmanufacture
Makeandmodel
Maximumamountofcover(retailvalue) R R
Typeofcover Comprehensive ComprehensiveClassofuse C C
C.Privateuseonly:Social,domestic,pleasurepurposesonly.
Enginecapacity
Importedormodified Yes No Yes No
Registrationnumber
Vehicleidentificationnumber
Enginenumber
Financehouse
Overnightparking Carport Carport
Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking
Registeredownerdetails
Nameandsurname
Identitynumber
Principaldriverdetails
Nameandsurname
Identitynumber
Gender Male Female Male Female
Maritalstatus Cohabitant Cohabitant
Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow
Additionaldriverterms
Additionaldrivers Yes No Yes No
Name,surnameandidentitynumber
1.
2.
3.
4.
5.
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Caravan/TrailerSection
Details Caravan/Trailer1 Caravan/Trailer2
Yearofmanufacture
Makeandmodel
Maximumamountofcover(retailvalue) R R
Typeofcover Comprehensive Comprehensive
Thirdparty,fireandtheft Thirdparty,fireandtheft
Thirdpartyonly Thirdpartyonly
Classofuse A B C A B C
A.Privateand limitedprofessionalandbusinessuse:Social,domestic,pleasureandprofessionaluse, includingtravel toandfromyour homeandpermanentplaceofwork,studyorprofession.B.Private,professionalandfullbusinessuse:Social,domestic,pleasure,professionalandfullbusinessuse, includingtravel toandfrom yourhomeandpermanentplaceofwork,studyorprofession.
C.Privateuseonly:Social,domestic,pleasurepurposesonly.
Importedormodified Yes No Yes No
Registrationnumber
Vehicleidentificationnumber
Enginenumber
Financehouse
Claimfreegroup
Overnightparking Carport Carport
Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking
Registeredownerdetails
Nameandsurname
Identitynumber
Optionalcover Maximumamountofcover Maximumamountofcover
Creditshortfall Yes No R R(Comprehensivecoveronly)
Additionallocksandkeys Yes No R R
Windscreen Yes No R R
PersonalLegalResponsibilitySectionCovered Maximumamountofcover
Personallegalresponsibility(Compulsory)
Yes No R2,500,000 R3,000,000 R4,000,000 R5,000,000
Optionalcover
Businessfromhome Yes No(included)
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ExtendedPersonalLegalResponsibilitySection
Covered Maximumamountofcover
Extendedpersonallegalresponsibility Yes No R10,000,000 R20,000,000
PersonalAccidentSectionCoveredperson
Nameandsurname
Identitynumber
(Dateofbirth/passportnumber)
Occupation
Specificcircumstancescovered Covered Maximumamountofcover
Death Yes No R
Permanenttotaldisablement(PTD) Yes No R
Temporarytotaldisablement(TTD)perweek
Yes No R
TTDnotexceeding104weeks Yes No R
Additionalmedicalexpenses(medicalcertificaterequired)
Yes No R
MotorPersonalAccidentSectionCovertype Anydriver Anypassengeranddriver Namedperson(s)
Ifnamedperson
Nameandsurname
Identitynumber
Yearofmanufacture
Makeandmodel
RegistrationnumberNumberofunits
Maximumamountofcover:Deathandpermanenttotaldisablement
Maximum amount of cover:Medicalexpenses
1. R250,000 R10,000
2. R500,000 R20,000
3. R750,000 R30,000
4. R1,000,000 R40,000
5. R1,250,000 R50,000
6. R1,500,000 R60,000
7. R1,750,000 R70,000
8. R2,000,000 R80,000
LegalCostsSection
Specificitemscovered Covered Maximumamountofcover
A R70,000
B R40,000Plantype
C R20,000 D R15,000
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WatercraftSectionVesselname
Vesseltype
Cruisingrange(Limited to South Africanterritorialwatersonly- Inlandwatersonly? Yes No
12nauticalmiles) Inlandandcoastalwaters? Yes No
Willthevesselbeusedoninlandwatersonly? Yes No
Ifno,Questionnaireistobecompleted.
Hullconstruction
Yearofmanufacturer
Vessellength
Unitofmeasure
Designspeed
Auxiliarymotors
Glitter
Claimfreegroup
Classofuse C
C.Privateuseonly:Social,domestic,pleasurepurposesonly.
Whatisyourboathandlingexperienceasaskipper?
Skippercertificate
Specificitemscovered Covered Maximumamountofcover
Hull Yes No R
Trailer Yes No R
Trailerdescription
Trailerregistrationnumber
Dinghy Yes No R
Auxiliarymotor(yachts) Yes No R
Specialequipment Yes No
Specialequipmentitemsdescription Maximumamountofcover
1. R
2. R
Inboard Yes No
Outboard Yes No
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Outboardmotordetails
Makeandmodel
Year
Serialnumber
Totalmaximumamountofcoverforwatercraftsection
R
Optionalextension Covered Maximumamountofcover
Roadorrailtransit Yes No R
Racingrisksails(yachtracing) Yes No R
Submergedobjects
Thirdpartyadditionalsumcovered(maximumlimituptoR750,000)Passengeradditionalsumcovered(maximumlimituptoR750,000)
Yes No R
Yes No R
Yes No R
Waterskiersextendedsumcovered Yes No R
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MonthlyDebitAuthority
Theinformationrequiredbelowistoenableyourmonthlycontributionstobedebitedfromyourbankaccount.Important:ifyouchangeyourbankaccountpleaseadvisetheCompanyimmediatelyandforwarddetailsofyournewaccount.
Intheeventthatthebankingdetailsbelowareinthenameofanotherperson,writtenconsentfromtheaccountholderisrequired.Intheeventthatthebankingdetailsbelowareinthenameofacompany,writtenconsent(fromthedirector)onthecompany’sletterheadandacancelledchequearerequired.
IherebydeclarethatZurichInsuranceCompanySouthAfricaLimitedisauthorisedtodebitthemonthlycontributionsfrommybankaccountstatedbelowandtoadjustsuchdebitasnecessaryduetochangesincover,risk,sumscoveredorcontributions.Nameofbank
Branchname
Branchnumber
Accountnumber
Nameofaccountholder
Typeofaccount
Shari’ahDeclaration
IagreetoparticipateintheTakafulWaqfFund“Fund”andthatmycontributionand/oranyinvestmentincomeoftheFund,shallbecreditedtotheFund.TakafulAfricaactingasTrusteesoftheFundhaveappointedZurichInsuranceCompanySouthAfricaLimitedtomanagetheFundinaccordancewiththerulesoftheFund.
IalsoagreethatmycontributionisanirrevocabledonationtotheTakafulWaqfFund.DeclarationConsenttoinformationsharingInsurersshareinformationwitheachotherregardingpoliciesandclaimswithaviewtopreventfraudulentclaimsandobtainmaterialinformationregardingtheassessmentofrisksproposedforinsurance.Byreducingtheincidenceoffraudandassessingrisksfairly,futurecontributionincreasesmaybelimited.Thisisdoneinthepublicinterestandintheinterestofallcurrentandpotentialparticipants.Thesharingofinformationincludes,butisnotlimitedto,informationsharingviatheInformationDataSharingSystemoperatedbyZurich’sserviceprovideronbehalfoftheSouthAfricanInsuranceAssociation.
Bythecompanyacceptingorrenewingthisagreement,youoranyotherpersonthatisrepresentedherein,giveconsenttothesaidinformationbeingdisclosedtoanyotherinsurancecompanyoritsagent.Youalsosimilarlygiveconsenttothesharingofinformationinregardtopastpoliciesandclaimsthatyouhavemade.Youalsoacknowledgethatinformationprovidedbyyourselforyourrepresentativemaybeverifiedagainstanylegallyrecognisedsourcesordatabases.Bycoveringorrenewingyouragreement,youherebynotonlyconsenttosuchinformationsharingbutalsowaiveanyrightsofconfidentialitywithregardtounderwritingorclaimsinformationthatyouhaveprovidedorthathasbeenprovidedbyanotherpersononyourbehalf.Intheeventofaclaim,theinformationyouhavesuppliedwithyourapplication,togetherwiththeinformationyousupplyinrelationtotheclaim,willbeincludedonthesystemandmadeavailabletootherinsurersparticipatingintheInformationDataSharingSystem.
Ideclarethattheinformationinthisapplicationis,tothebestofmyknowledgeandbelief,trueandaccurateineveryrespectandthatnofact,circumstanceorhazardthatcouldaffecttheacceptanceofmyapplicationhasbeenwithheld.IconfirmthatthisapplicationanddeclarationshallbethebasisofthisagreementbetweenTakafulAfrica,ZurichInsuranceCompanySouthAfricaLimitedandmyself.
Lastly,IalsoconfirmthatIwillnotbeabeneficiaryoftheTakafulWaqfFunduntilthisapplicationhasbeenacceptedandanycontributionsduehavebeenpaidinfull.
Signedat____________________________________________onthe__________dayof________________________20_____
Signatureofparticipant
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ContentsInventoryatNewReplacementValue
Bedroom 1 2 3 4
Mattresses
Bedsideradios
Tables,chairs,wardrobes
Curtains,loosecarpets
Paintings,ornaments
Linen,blankets,bedding
Clothing,footwear
Furs,jewellery
Lamps
ToysTVset,video,hi-fi
Other
TotalR
Study/workroomDesk,bookcases
Tables,chairs
Curtains,loosecarpets
Paintings,ornaments
Sewing,knittingmachine
Camera,projector
Firearms,binoculars
Typewriter,PC,faxmachine
Sportingequipment
Readinglamps
Other
TotalR
Bathroom/toilet 1 2
Curtains,loosecarpets
Towels,linen
Shavingequipment
Hairdryer
Toiletries
Other
TotalR
Passage/entryhallTables,chairs
Curtains,loosecarpets
Paintings,ornaments
Householdheaters
Linenstored
Other
TotalR
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LaundryWashingmachine
Tumbledrier
Iron,ironingboard
Curtains
Linenstored
Other
TotalR
LoungeLoungesuite
TV,video,videogames,DVDs
Hi-Fi/Tapedeck,CDplayer
Records,tapes,CDs,DVDs
Displaycabinet,articles
Curtains,loosecarpets
Paintings,ornaments
Readinglamps
Glassware
Other
TotalR
FamilyroomTV,video,videogames,DVD
Hi-Fi/Tapedeck,CDplayer
Records,tapes,CDs,DVDs
Tables,chairs
Curtains,loosecarpets
Paintings,ornaments
Furniture,chairs
Readinglamps
Glassware
Other
TotalR
DiningroomDresser,sideboard
Tables,chairs
Crockery,glassware
Cutlery,silverware
Linenstored
Readinglamps
Displayarticles
Hottray
Curtains,loosecarpets
Teatrolley
TotalR
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KitchenFridge/freezer
Dishwasher
Mixer,blender
Vacuumcleaner,polisher
Electricalappliances
Cutlery,crockery,glassware
Furniture,chairs
Groceries
Utensils
Microwaveoven
Other
TotalR
Garage/workshopPower/handtools
Workbench,vice
Bicycles
Lawnmover,roller
Gardenfurniture
Gardenimplements
Braaiequipment
Campingequipment
Swimmingpoolequipment
Weldingequipment
Other
TotalR
DomesticemployeeBed,mattress
Wardrobe
Tables,chairsCurtains,loosecarpets
Paintings,ornaments
Linen,blankets,bedding
Clothing,footwear
Radio,TV,video
Other
TotalR
GrandTotalR
AdditionalInformation/Comments
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