RISK ANALYSIS / AMENDMENT FORM

AMENDMENT FORM / RISK ANALYSIS FORM
SECTION A – PERSONAL INFORMATION
This is an ELECTRONIC fillable form – Please make sure you complete all the sections that is applicable on you and answer every question as omission of info can lead to repudiation of your claim
DO YOU WANT TO AMEND OR ADD AN ITEM TO YOUR EXISTING POLICY OR DO YOU NEED A TOTAL NEW QUOTE?*
Name*

First NameLast Name
ID number:*
Contact Details
(Cell)*
E Mail:*
example@example.com
Current home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
RISK ANALYSIS
Are you currently insured?

YesNo
If Yes, through which company
Please upload your latest schedule here or send it to mb@lumbt.co.za

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Occupation
Marital Status
Did you have any claims or losses in the last 3 years?

YesNo
If Yes, please add detail below, Click the plus to add a line.*
Please upload the claims history from your current insurer.

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PLEASE ANSWER THE FOLLOWING QUESTIONS
1.Has any insurer or underwriter ever declined to accept or refused to renew or imposed any special terms on your Insurance?

YesNo
2. Has any persons who may drive any of the vehicles to be insured been refused motor insurance and/or had their drivers licence been endorsed or suspended?

YesNo
3. Do you or any other person who is to be insured by this policy suffer from any physical defect or infirmity?

YesNo
4. Are you aware of any material information, requested or not, that would affect the acceptance of a possible proposal?

YesNo
5. Have you ever been or are you currently declared insolvent, under judicial management, credit counseling?

YesNo
6. Have you ever had any criminal convictions or do you have any criminal cases pending against you?

YesNo
If Yes to any question above, please elaborate:
PICK THE SECTIONS TO BE INSURED/AMENDED

We do not insurer vehicles only. House hold is compulsary
What do you want to add or amend? NOTE - Water craft or Motor Cycle Trailers need to be insure under Vehicle section.

Address Change / House Content / Home owners (Buildings)All Risk itemsVehicleMotor CycleCaravan / TrailerWater Craft
HOUSEHOLDERS SECTION - CONTENT

House hold insurance is compulsory with your package.
Value of the content?
If you are unsure of the value, please complete the INVENTORY FORM
When are you moving/From when do you need cover?

DayMonthYear
Date
New risk Address if different form the address above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Questions regarding your new residence:
1. Will you be going on leave in the next 30 days?

YesNo
2. Will the residence be left unoccupied for more than 30 days per year?

YesNo
3. Are you the sole owner/resident of the residence?

YesNo
4. Does someone who is not part of your immediate family reside in the residence?

YesNo
5. Do you or anybody else run a business or hobby from the residence?

YesNo
If Yes to one of the questions, please elaborate:
SECURITY AT THE NEW PREMISES

Security in and around the residence
1. Burglar bars in front of all opening windows (Main residence as well as outbuildings)?:

YesNo
2. Steel security gates in front of all doors (Main residence as well as outbuildings)

YesNo
3. Is your Alarm linked via radio to a 24 hour manned control room, with 24 h armed reaction?

YesNo
4. Does the residence have a fence or wall all around?

YesNo
If No to one of the questions, please elaborate:
QUESTIONS REGARDING THE CONSTRUCTION

The building it self.
1. Type of residence
2. Roof construction of house:
3. Wall construction of house:
4. Where is the residence situated:
5. Is any of the following in the immediate vicinity of the residence?
Value of the property:
If you are the owner, do you need home owners insurance? (Bank can be expensive!)*

YesNo
Type: Is the building

Building is FinancedIs a Holiday homeIs hired or let out
Occupation type
Construction type
Subsidence and Landslip Cover Type
Bond Holder
Sum Insured
Effektive date

DayMonthYear
Date
Do you stay in a security complex or estate?*

YesNo
SECURITY COMPLEX QUESTIONNAIRRE:

Please complete the questions and elaborate if yes.
Is there controlled access to the complex, in other words does a guard contact residents to get permission?

YesNo
Do guards patrol the premise 24 hours?

YesNo
Does the complex have an electric fence?

YesNo
Is there radio communication between all guards?

YesNo
Are there any incomplete building activities in the complex?

YesNo
Have there been any burglaries or hijackings in the complex?

YesNo
If any of the questions was answered Yes, please elaborate:
ALL RISKS SECTION

Valuables that you take with you like Cell phones, Laptops, Jewelry, Camping equipment, Rooftop tents, Awnings that is not part of the vehicle.
(Clothing and personal items on person when leaving home – Click link for examples of what must be specified)

Unspecified items: R7 500 Min or increase to Higher value
Which items do you want to cancel or replace?
1. Do you want to specify an Item?

YesNo
1. What items do you want to specify?
Description
Serial / IMEI Number
Sum insured for
Take a picture of the Invoice, S/N as proof of ownership
2. Do you want to specify another item?

YesNo
2. What items do you want to specify?
Description
Serial / IMEI Number
Sum insured for
Take a picture of the Invoice, S/N as proof of ownership
3. Do you want to specify another item?

YesNo
3. What items do you want to specify?
Description
Serial / IMEI Number
Sum insured for
Take a picture of the Invoice, S/N as proof of ownership
4. Do you want to specify another item?

YesNo
4. What items do you want to specify?
Description
Serial / IMEI Number
Sum insured for
Take a picture of the Invoice, S/N as proof of ownership
5. Do you want to specify another item?

YesNo
5. What items do you want to specify?
Description
Serial / IMEI Number
Sum insured for
Take a picture of the Invoice, S/N as proof of ownership
6. Do you want to specify another item?

YesNo
6. What items do you want to specify?
Description
Serial / IMEI Number
Sum insured for
Take a picture of the Invoice, S/N as proof of ownership
MOTOR SECTION

Make sure you mention the regular driver of any of the vehicles if other than yourself driving the vehicle more than 51% of the time.
1. Vehicle to be insured
Type of vehicle:*
Year model:*
If it is a Pre-Owned vehicle you need to take it to PG Glass for inspection within 7 days otherwise you will only have thirdparty cover. Please confirm that you have read this by click below.*

I Confirm that I have read and understand the consequences of the above
Full description of vehicle including manual or auto:*
Eg. FORD Ranger 3.2 Auto D/C 4x4
Value of the vehicle excluding extras*
M&M Code as per OTP
Type of cover*
Use of vehicle*
Vehicle Details

Available on the OTP(Offer to purchase) from the dealer or the License disk
Reg. No:*
Engine No:*
VIN No:*
Colour:
Security in vehicle:
Tracking device installed
Upload the OTP or take an picture below

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Upload Security Certificate or take a picture below

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Take Picture of the OTP or the License disk
Take Picture of Security Certificate
Vehicle Extras

Note - Rooftop tents & Awnings must be specified under All Risk.
Exstras on your vehicle(Click + to add an item)*
Select the cover you want. (Click + to add more lines)*
Owner and driver details
Registered owner

First NameLast Name
ID No of Owner
Is the regular driver some else as the owner? (Drive more than 51% of the time)

YesNo
Regular driver(more than 51% of the time)

First NameLast Name
ID No of regular driver
License date of regular driver

DayMonthYear
Date
Overnight address - Vehicle 1:

Current home addressNew home addressOther address - insert below
Overnight address - Vehicle 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want to insure another?

YesNo
2. Vehicle to be insured
Type of vehicle*
Year model*
If it is a Pre-Owned vehicle you need to take it to PG Glass for inspection within 7 days otherwise you will only have third party cover. Please confirm that you have read this by click below.

I Confirm that I have read and understand the consequences of the above
Full description of vehicle including manual or auto*
Eg. FORD Ranger 3.2 Auto D/C 4x4
Value of the vehicle excluding extras*
M&M Code as per OTP
Type of cover*
Use of vehicle*
Vehicle Details

Available on the OTP from the dealer or the License disk
Reg. No:*
Engine No:*
VIN No:*
Colour:
Security in vehicle:
Tracking device installed
Upload the OTP or take an picture below

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Upload Security Certificate or take a picture below

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Cancelof
Take Picture of the OTP or the License disk
Take Picture of Security Certificate
Vehicle Extras

Note - Rooftop tents & Awnings must be specified under All Risk. Insert the value of the item you want to insure.
Exstras on your vehicle(Click + to add an item)*
Select the cover you want. (Click + to add more lines)*
Owner and driver details
Registered owner

First NameLast Name
ID No of Owner
Is the regular driver some else as the owner? (Drive more than 51% of the time)

YesNo
Regular driver(more than 51% of the time)

First NameLast Name
ID No of regular driver
License date of regular driver

DayMonthYear
Date
Overnight address - Vehicle 2:

Current home addressNew home addressOther address - insert below
Overnight address - Vehicle 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTOR CYCLE SECTION

NOTE: Freezers, Trailer & Rooftop tents need to be specified.
1. Motor Cycle/Quad Bike to be insured
Type of Motor Cycle*
Year model*
Full description of vehicle including manual or auto*
Eg. BMW 1200 RS
Value of the vehicle excluding extras*
Exstras on your vehicle(Click + to add an item)*
Additional cover you want. (Click + to add more lines)*
Motor Cycle Details

Available on the OTP from the dealer or the License disk
Reg. No:*
Engine No:*
VIN No:*
Security in vehicle:
Tracking device installed
Motor cycle extras
Upload OTP/Invoice

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Upload certificate Security certificate on the vehicle

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Owner and driver details
Registered owner

First NameLast Name
ID No of Owner
Is the regular driver some else as the owner? (Drive more than 51% of the time)

YesNo
Regular driver(mire than 51% of the time)

First NameLast Name
ID No of regular driver
License date of regular driver

DayMonthYear
Date
Overnight address - Motor Cycle:

Current home addressNew home addressOther address - insert below
Overnight address - Motor Cycle

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want to insure another?

YesNo
CARAVAN AND TRAILER SECTION

Add on's eg. trailer tens, freezer, awnings must be specified under All Risk Section
1. Caravan/Trailer to be insured
Type of Caravan/Trailer*
Year model*
Full description of vehicle including manual or auto*
Eg. BMW 1200 RS
Value of the vehicle excluding extras*
Exstras on your vehicle(Click + to add an item)*
Caravan/Trailer details

Available on the OTP from the dealer or the License disk
Reg. No:*
VIN No:*
Upload OTP/Invoice

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Owner details
Registered owner

First NameLast Name
ID No of Owner
Overnight address - Caravan/Trailer:

Current home addressNew home addressOther address - insert below
Overnight address - Caravan/Trailer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want to insure another?

YesNo
SECTION I - WATER CRAFT
Type of vessel: Note that the trailer must be insured sepratly under the motor section.

Motor boatJetskiDinghyRow boat/ CanoSail boat/YachtWind surfer
Make:
Model:
Sum isured - Hull
Year model
Sum insured: Trailer:
Type of cover*
Speed / Horsepower:
Inland / Coastal:
Registered owner:
Overnight Address - Watercraft

Current home addressNew home addressOther address - insert below
Overnight Address - Watercraft

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*
The following documentation may be needed at claim stage. Feel free to send them up front to help to speed up the proses at claim stage

ID, Card License, Registration certificate, Tracking device certificates, Proof of previous insurance/insurer and claims history
Upload or take a picture of any of the above documents here. You can add multiple documents! If the files are to big, please emaIl them to mb@lumbt.co.za

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DECLARATION BY CLIENT
I declare that the information given above and any other information supplied by yourself or on your behalf is true, correct and accurate in every respect and that no fact, circumstance or hazard that could affect the acceptance of your application has been withheld.

You acknowledge that the sharing of insurance information for underwriting and claims purposes (including credit information) between insurers is in the public interest as it enables insurers to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims with a view to limiting premiums.

On your own behalf and on the behalf of any person you represent herein, you hereby waive your right to privacy with regard to underwriting or claims information (including credit information) that you provide or that is provided by another person on your behalf in respect of any insurance policy or claim made or lodged by you.

You acknowledge that the insurance information provided by yourself may be stored in the shared database and used as set out above as well as for any decision pertaining to the continuance of your policy or the meeting of any claims you may submit.

You consent to such information being disclosed to any other insurance company or its agent and that the information may be verified against legally recognized sources or databases.
Name*

First NameLast Name
Date:*

DayMonthYear
Date
By submitting, an email with your answers will be send to you and Luminis Brokers.
Thank you for your time and effort to help us to insure you correctly.

AMENDMENT FORM / RISK ANALYSIS FORM

SECTION A – PERSONAL INFORMATION

Contact Details

RISK ANALYSIS

PLEASE ANSWER THE FOLLOWING QUESTIONS

HOUSEHOLDERS SECTION - CONTENT

Questions regarding your new residence:

SECURITY AT THE NEW PREMISES

QUESTIONS REGARDING THE CONSTRUCTION

SECURITY COMPLEX QUESTIONNAIRRE:

ALL RISKS SECTION

MOTOR SECTION

1. Vehicle to be insured

Vehicle Details

Vehicle Extras

Owner and driver details

2. Vehicle to be insured

Vehicle Details

Vehicle Extras

Owner and driver details

MOTOR CYCLE SECTION

1. Motor Cycle/Quad Bike to be insured

Motor Cycle Details

Owner and driver details

CARAVAN AND TRAILER SECTION

1. Caravan/Trailer to be insured

Caravan/Trailer details

Owner details

SECTION I - WATER CRAFT

DECLARATION BY CLIENT