Client Identification
Who holds the policy and who is submitting the request.
Cover cannot be bound before the insurer receives this form.
Registration & Identity
The identifiers the insurer uses to schedule the vehicle.
Also shown as the chassis number on the licence disc — capture it once here.
An expired disc can prejudice a claim.
Make & Specifications
Technical detail that determines rating and use class.
Insurers often require a fitment certificate.
Value & Use
What the vehicle is worth, how it is valued, and how hard it works.
The sum insured before extras.
Retail for new, market for used.
Non-standard extras fitted
List aftermarket or non-standard items with their individual values. These are added to the sum insured. Leave blank if none apply.
| # | Description of extra / fitment | Value (R) |
|---|
Ownership & Finance
Who owns it, who finances it, and whose interest must be noted.
Complete if the registered owner is not the policy holder.
The finance house is usually first loss payee.
Cover Options & Submission
Elect additional cover and excess reducers, then sign off.
Additional cover required
Select yes or no for each. Where yes, give the limit or detail the insurer needs.
| Description | Cover required? | Details / limit |
|---|
Excess reducer options
Reducers lower the excess payable at claim stage for an additional premium.
| Description | Reducer required? | Details / limit |
|---|
Additional notes & instructions
Anything the insurer or underwriter should know that the fields above do not cover — special conditions, prior damage, fitment or inspection arrangements, or instructions for the broker.
Appears on the generated PDF as its own section.
Declaration
Confirmation of receipt will be sent to this address.