081 208 5809 / 021 830 5256 info@omnigroup.co.za

Leisuresure Insurance Proposal Form

Brokerage Name: Omni Group PTY LTD
Department: Sales
Has any Insurer at Any Time:
Underwriting Questions
1. During the past three years, have you, or any other named riders:
2. Have you, or any named rider;
Claims / Accident / Loss History (Past 3 Years) - Insured or Named Rider
I hereby declare that the above information supplied by me is true and correct, and I understand that should this information ever be proved to be false or untrue, it may lead to the denial of any liability and cancellation of my cover.
All Risks Section (Riding Gear)

Please list all items making sure a replacement value is indicated per item

Motor Section
Motorcycle 1
Motorcycle 2
Extra's fitted to the motorcycle/s

Please list all items making sure a replacement value is indicated per item

Please list all items making sure a replacement value is indicated per item

Policy Limit
Motorcycle 1
Motorcycle 2
Vehicle Security
Motorcycle 1
Motorcycle 2
Finance House
Motorcycle 1
Motorcycle 2
Dealership Details
Motorcycle 1
Motorcycle 2
Security Requirements
  1. Vehicles with Sum Insured up to R199 999 are required to be kept in a locked garage or chained to a fixed object
  2. Vehicles with Sum Insured exceeding R200 000 are required to be fitted with an approved Tracking Device
  3. Vehicles not kept in a locked garage when not in use must be chained to a fixed object not visable from the perimeter of the address stated on the schedule or fitted with an IUM approved tracking device.
  4. Theft Cover - Your motorcycle needs to be kept behind locked gates or in a locked garage at night.
Special Conditions
  1. Unless otherwise arranged, cover is restricted to the named rider stated in the proposal.
  2. Track school cover will be included subject to the prior notification in writing from the insured prior to the event and confirmation of acceptance has been received by the insured from IUM.
  3. Motorycle inspections: If bought from a dealer we would need a copy of the dealer invoice, if bought privately we would need pics of the motorcycle (Front, back and both sides & a pic of the clocks with engine on…)
  4. Vehicle's will be insured for retail value
Compulsory Copies of Documents Required (Copies Attached)
Rider Documents
Named Rider Documents
Debit Order Authority
I / we hereby request and authorise the insurer(s), and / or their collection agent(s) to draw against the above account (or any other bank or branch whom I/ we may transfer my/our Account) the amount necessary for the payment of the monthly premiums due to them in respect of the insurance herein proposed on the day indicated above of each and every month commencing on the commencement date of the insurance and continuing all such withdrawals from my / our bank shall be treated as though they had been signed by me/ us personally. I / we understand that the withdrawals hereby authorised will be processed by computer through a system known as ACB magnetic tape service, and I/ We also understand that the details of each withdrawal will be printed on my / our bank account statement or on an accompanying voucher. I / we agree to pay any bank charges relating to this debit order instruction. This authority may be cancelled by me / us giving the insurer 30 days notice in writing, but I / we shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force if such amounts are legally owing to you. I / We also authorise the insurer and / or their collection agents to deposit direct to the above account, any amounts which may be due to me / us either in respect of any refund premiums of any amounts due to me / us in settlement of any claim. The amount of the debits may vary from time to time to reflect any changes in cover, risk, sums insured and / or premium rates.
I / we declare that: the answers given above are true and correct in every respect and that I / we have answered all the relevant questions. I / we will give immediate notice to the insurer of any alteration of the risk herein submitted. I / we have not concealed any material facts which should be communicated to the insurer. Unless any facts material to this proposal for insurance are embodied in this proposal form they shall not be considered communicated to the insurer even if disclosed to such broker. I / we agree that this proposal form shall be the basis of the contract of insurance hereby applied for. I / we are willing to accept a policy subject to the terms and conditions contained herein and I / we understand that no insurance will be in force until the IUM has signified acceptance of this proposal in writing to your broker.
Your signature here encompasses all the pages and fields on this form


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