25-01-2005

14:31:27
INSURANCE BROKERS NAME

SCHEDULE

POLICY NUMBER: YB0001

SCHEME: DOMESTIC LINES (REGENT)

POLICY IS UNDERWRITTEN BY: Underwriter

ADMINISTERED BY: Policy Administrators Name Here   Reg No: 2000/016241/07

PHONE: (011)888-8888   FAX: (011)888-8880   email: Agent@Email.co.za

Broker:

Postal Address:

 

Email address:

Contact Person:
 Insurance Broker

 P O Box 000

 Randburg

 

 2125

 

 broker@email.co.za

 Broker Agent Name

Office Address:

 

 

Telephone:

Fax:

Cellular:

 121 Brokers Office Address

 Johannesburg

 

 2125

 0118822222

 0117222222

 

Client number:

The Insured:

Postal address:

Email address:
 009639

 Mr DJ Robertson

 32 Home Address

 Johannesburg

 

 1709

 dean@isp.co.za
ID Number:

Date of Birth:

Occupation:

Home Phone no:

Work Phone no:

Cellular phone no:

Fax no:
 0501255080089

 25-01-2005

 It Director

 0115555555

 0114444444

 0835555555

 0113333333

Cover is effective from 01/04/2003 and any uninterrupted period for which the full premium has been paid for after this date.
Bank:
FIRSTRAND BANK
Branch:
RANDBURG,TVL 041
Account Type:
Cheque
Account Holder:
C.A.B
Bank Code:
****** ( Always Hidden )
Account Number:
*********** ( Always Hidden )

HOUSE OWNERS
Sum Insured
Premium
Risk Address:
32 Home Address, Johannesburg, , 1709
R1,250,000
R239.58
Type of Building:
House
Wall construction:
Brick
 Unoccupied: No
Roof construction:
Tiles
 Landslip cover: No
No claim bonus:
none
Voluntary Excess:
none
The interest of FNB is noted.
Monthly Premium
R239.58

HOUSE CONTENTS
Sum Insured
Premium
Risk Address:
32 Home Address, Johannesburg, , 1709
R331,276
R205.96
Type of Building:
House
Unoccupied:
No
Wall construction:
Brick
Theft cover exclude:
No
Roof construction:
Tiles
High security complex:
No
No claim bonus:
5 Years
Electric Fences:
No
Voluntary Excess:
none
Occupied During Day:
No
Inventory Form:
Outstanding
Accidental Damage:
Yes
Alarm Certificate:
Outstanding
Linked Alarm:
Yes
Monthly Premium
R205.96

ALL RISK ITEMS
Sum Insured
Premium
Masker Driver and 3 Wood
R4,500
R18.75
Item Type:
Golf Equipment
Valuation Certificate:
Outstanding
9ct 45cm Bi-col Gold Chain
R3,700
R15.42
Item Type:
Jewellery
Valuation Certificate:
Outstanding
Panasonic Video Camera Vx27
R5,000
R21.00
Item Type:
Jewellery
Valuation Certificate:
Outstanding
Cz75 9mm Parabellum Fire Arm
R2,300
R9.60
Item Type:
Jewellery
Valuation Certificate:
Outstanding
Michele Herbaline Ladies Wat
R5,200
R21.67
Item Type:
Jewellery
Valuation Certificate:
Outstanding
Mizuno Golf Clubs
R6,000
R25.00
Item Type:
Jewellery
Valuation Certificate:
Outstanding
Ladies Yellow/white Gold Ring
R7,000
R29.17
Item Type:
Jewellery
Valuation Certificate:
Outstanding
Sony F717 Digital Camera
R9,500
R39.58
Item Type:
Other
Valuation Certificate:
Outstanding
Trek Trick Bike
R1,600
R14.67
Item Type:
Pedal Cycles
Valuation Certificate:
Outstanding
Monthly Premium
R194.86

MOTOR VEHICLE
Sum Insured
Premium
Make & Model:
2003 - B M W 318ti (E46) 01/05
R195,000
R529.49
Accessories:
Metallic Paint R1700 and Leather Trim R9200.00
R10,900
Excess Reducer:
R0
Registration:
TBA
Tracking Device:
Matrix
Vehicle Type:
Sedan Vehicle
Gearlock:
none
Cover Type:
Comprehensive
Car Hire:
No
Use:
Private Use
No Claim Bonus:
5 Years
Voluntary Excess:
none
Auto Value Adjust:
No
Immobiliser:
none
 
1st Nom. Driver:
A Nother
Date of Birth:
11/04/1972
2nd Nom. Driver:
N Other
Date of Birth:
10/07/1970
Tracking Certificate
Received
 
Monthly Premium
R529.49

POLICY SUMMARY
Commission
Sum Insured
Premium
House Owners
R47.92
R1,250,000
R239.58
House Contents
R41.19
R331,276
R205.96
All Risk Specified
R38.97
R44,800
R194.86
All Risk Unspecified
R0.00
R0
R0.00
Motor Vehicles
R66.19
R205,900
R529.49
Motor Cycles
R0.00
R0
R0.00
Caravan/Trailers
R0.00
R0
R0.00
Watercraft
R0.00
R0
R0.00
Personal Accident
R0.00
R0
R0.00
Public Liability
R0.00
R0
R0.00
SASRIA
R6.68
Funeral Plan
R0.00
Add-On Products
R0.00
Brokers Fee
R0.00
Administration Fee
R60.00
Policy Fee
R0.00
14% VAT Included
Monthly Premium
R1,236.57