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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

BROKER INFORMATION Broker: Broker Fee: R % Quote Number: Quote Amount:

CLIENT INFORMATION Full Name of Policy Holder: I.D/Company Registration Number: VAT Number: Gender: Male Female Occupation: Marital Status: Contact Number: Home Contact Number: Cell Contact Number: Work Contact Number: Fax E-mail Address: Address: Residential Address: Postal

DEBIT ORDER AUTHORITY POLICY DETAILS Inception Date: Payment Frequency: Monthly Annually BANK DETAILS Bank: Branch Name: Branch Code: Account Number: Account Holder: Type of Account: Current Transmission Savings Authorisation by Account Holder I hereby authorise Echelon Private Client Solutions (Pty) Ltd, on behalf of Santam Ltd, to debit my bank account noted above

Signature of Account Holder:

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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

RISK INFORMATION - MOTOR VEHICLE 1 VEHICLE 2

Make: Model: Year of Manufacture: Registration Number: Details and Value of Accessories: Details and Value of Audio Equipment (If not Factory Fitted): Retail Value of Vehicle: Transmission: Manual Manual Automatic Automatic Engine Number: Vin Number: Registered Owner: Overnight Storage: Locked Garage Locked Garage Locked Basement Locked Basement Carport behind Carport behind Locked Gates Locked Gates Driveway behind Driveway behind Locked Gates Locked Gates Driveway - Driveway - No Locked Gates No Locked Gates Secure Complex Secure Complex On Street On Street Vehicle Located at (Address): Current Vehicle Security: Tracking Device Details: Car-Hire: Standard Standard Executive Executive (Group F - (Group F - Extra R45p/m) Extra R45p/m) SUV SUV (Group K – (Group K - Extra R90p/m) Extra R90p/m) Name of Main Driver: Main Driver I.D No./Age: Main Driver Gender: Male Male Female Female Main Driver Marital Status: Main Driver Occupation:

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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

VEHICLE 1 VEHICLE 2

Use of Vehicle: Business Business Private Private

Both Both

CFG of Main Driver: (Copy of schedule to be Provided) Bank Interests to be Noted: 3 Year New for Old: Yes Yes No No Excess Waiver (up to R30 000): Yes Yes No No Excess Waiver (up to R60 000): Yes Yes No No Credit Shortfall: Yes Yes No No Extended 4x4: Yes Yes No No Motor Personal Accident (MPA): Yes Yes No No MPA Passenger Extension: Yes Yes No No MPA Maximum Indemnity Limit: R 250,000 R 750,000 R 500,000 R 1,000,000

RISK INFORMATION – MOTOR CYCLES MOTORCYCLE 1 MOTORCYCLE 2 Make: Model: Year of Manufacture: Registration Number: Category: Off-road Bike Off-road Bike Quad Quad Superbike Superbike Roadbike/Tourer Roadbike/Tourer Scooter Scooter

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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

MOTORCYCLE 1 MOTORCYCLE 2 Engine Number: Frame Number: Registered Owner: Name of Main Driver: Main Driver I.D No./Age:

Main Driver Gender: Male Male Female Female Overnight Storage: Locked Garage Locked Garage Locked Basement Locked Basement Carport behind Carport behind Locked Gates Locked Gates Driveway behind Driveway behind Locked Gates Locked Gates Driveway - Driveway - No Locked Gates No Locked Gates Secure Complex Secure Complex

Vehicle Located at (Address): Current Vehicle Security:

RISK INFORMATION – PREMISES 1 PREMISES 2 BUILDINGS/CONTENTS Risk Address: Type of Residence: House House Apartment Apartment Townhouse Townhouse Cluster Cluster Farm Farm Holiday House Holiday House Other Other Construction - Roof: Standard Standard Non-std Non-std Thatch Thatch

Construction - Walls: Standard Standard Non-standard Non-standard Subsidence & Landslip: Yes Yes (Complete Questionnaire) (Complete Questionnaire) No No

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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

PREMISES 1 PREMISES 2 Occupied by: Owner Owner Tenant Tenant

Occupied during the day: Yes Yes No No Security: Burglar Bars on Burglar Bars on Opening Windows Opening Windows Security Gates on Security Gates on External Doors External Doors 24 Hour Alarm linked 24 Hour Alarm linked to Armed Response to Armed Response Electric Fence linked Electric Fence linked to Armed Response to Armed Response Response Co. Name : Patrolled by Patrolled by Security Guards Security Guards Secure Estate Secure Estate Unoccupied Longer Unoccupied Longer than 60 Days than 60 Days

CFG : (Copy of schedule to be provided)

Interests to be noted: Maximum Indemnity/Buildings Main Building: Main Building: (Please ensure all outbuildings are R R included. Premium and claims settlement will be based on the value of all buildings on the premises) Outbuildings: Outbuildings: R R

TOTAL TOTAL R R Maximum Indemnity/Contents: Contents at Premises: Contents at Premises: R R Jewellery/Watches Jewellery/Watches at Premises: at Premises: R R Items in Bank Vault: Items in Bank Vault: R R TOTAL TOTAL R R Risk Assessment Required: Building Building Contents Contents

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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

PREMISES 1 PREMISES 2 Excess Waiver: Building Building Contents Contents Extended Business Contents : Yes Yes No No RISK INFORMATION - PERSONAL ALL RISKS Unspecified Personal All Risks: R (Limited to 20% of Maximum Indemnity for Contents) Specified Items and Values: DESCRIPTION SERIAL NO. IN BANK VAULT (Y/N) VALUE

R

R R R R R RISK INFORMATION – AIRCRAFT Please complete supplementary aircraft proposal. RISK INFORMATION - WATERCRAFT Type of Craft: Rigid Semi-Rigid Full Inflatable Semi-Inflatable Jetski/Wetbike Construction of Hull: Details of Motor/s: Storage when not in Use: Locked Garage Driveway behind Locked Gates Locked Basement Driveway – No Locked Gates Carport behind Locked Gates Secure Complex Use of Vessel: Inland Only Inland and Coastal Coastal and Surf Launch Name of Pilot: Date of Birth of Pilot: Experience of Pilot (Years): Date of Skipper's Licence: Sum Insured: Hull: R Details : Motors R Details: Accessories R Details: TOTAL

R

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Johannesburg Telephone No.: 011 023 2214/5/6/7/8 Fax No.: 011 463 5796 Cape Town Telephone No.: 021 657 1100 Fax No.: 021 683 5441

Echelon Private Client Solutions (Pty) Ltd is an authorised financial services provider (licence number 40613)

COMBINED PROPOSAL

RISK INFORMATION – CARAVANS/TRAILERS Make and Model: Year of Manufacture: Sum Insured:

RISK INFORMATION - PERSONAL ACCIDENT Full Name: I.D Number: Maximum Indemnity Limit: R 100,000 R 250,000 R 500,000 R 750,000 R 1,000,000 R 1,500,000 R 2,000,000

Domestic Employee Extension: Yes No

RISK INFORMATION – ADDITIONAL BENEFITS

Identity Theft Yes No

Retrenchment Benefit: Yes No

Roadside/Home Assistance: Yes No LOSS HISTORY & GENERAL INFORMATION Does the Policyholder/Client/Main Driver or any other driver, suffer from defective vision, hearing or from any physical or mental infirmity? Yes No

Please provide details: Is the Policyholder/Client/ Main Driver or other driver's licence currently endorsed, or has it previously been endorsed?

Yes No

Please provide details: Has the Policyholder/Client/Main Driver suffered any losses, insured or otherwise, in the past 5 years?

Yes No

DETAILS OF INCIDENT YEAR AMOUNT CLAIMED Has any insurer ever refused any proposal of yours, cancelled any policy (or section thereof), refused to renew or imposed any special conditions on any policy (or section thereof) Yes No If yes, please provide full details: Please provide details of your current insurance policy:

WARRANTY I hereby warrant that the above particulars and statements are true and complete and contain all information known to me affecting the risks to be insured and that this and any other statement made by me or on my behalf for the purpose of the proposed insurance shall be the basis of and incorporated in the contract between me and Santam Limited herein represented by Echelon Private Client Solutions (Pty) Ltd t/a Echelon and shall be promissory. I agree to accept the insurance on the terms and conditions set forth in the policy. Date Signature of Policy Holder