Personal Lines Application Form

RFG WEALTH APPLICATION FORM

An Authorised Financial Services Provider - FSP 51227
Broker:
Date Insurance to begin:

MonthDayYear
Date
PLEASE NOTE: If you are currently have insurance in place and do not need to add or remove any cover items, you do NOT need to fill in the rest of this application. Only attach your most recent Policy Schedule.

Attach Current Policy Schedule
Cancelof
Personal Information
Name*

First NamesLast Name
ID Number *
South African Identity Number
Email*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityProvince

Postal / Zip Code

Insurance History
1. Has any insurer ever cancelled your insurance, applied special terms or refused a quotation?*
If yes, provide details:
2. Have you or anyone you intend covering under this policy been sequestrated or has a company that you or anyone you intend covering under this policy been liquidated in the last 5 years?*
If yes, provide details:
3. Are you or any business entities you have an interest in or any person you intend covering under this policy currently under administration or debt review?*
If yes, provide details:
4. Previously held insurance for any of the sections applying for?*
If yes, provide details:
Insurer, Cover Type & Date
5. Have you ever made a claim against an insurer in the last three (3) years? *
If yes, provide details:
Insurer, Date, Claim Type, Claim Amount

All Risk Section

Portable Possessions
YesNo
Unspecified Items (wearing apparel etc.)
Cover Value (Please note that All high value items needs to be specified)

Specified Items (High Value Items, e.g Cellphone)

RFG WEALTH APPLICATION FORM