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PersonalTakafulAgreementApplicationtoparticipate

Importantnotes1.PleaseprintinBLOCKLETTERS.2. Noagreementisinforceuntilwehavereceivedthefullycompletedandsignedapplicationformandconfirmedcover.Ifwedeclineyourapplication,wewillnotifyyouoryourbrokerimmediately.

3.Please(!)theapplicableblocksforyes/noanswers.4.Ifinsufficientspaceisavailableontheformpleaseprovideanswersonthelastpageunder“AdditionalInformation/Comments”.

BrokerDetailsAgency/broker

Agencynumber

CoverRequiredCoverisavailableforthefollowingclasses.Please(!)theclassesyourequirecoveronandcompletetherelevantsectionsintheapplicationform.

NoapplicationisrequiredforSasriaasitisautomaticallyincluded(N.B.SasriadoesnotformpartofyourPersonalTakafulAgreement)

Section

Buildings(Home) MotorCycles PersonalAccident

HouseholdContents Caravan/Trailers MotorPersonalAccident

SpecificItems(AllRisks) PersonalLegalResponsibility LegalCosts

PersonalComputerEquipment ExtendedPersonalLegalResponsibility Watercraft MotorVehicles

PersonalDetailsFirstname(s)

Surname

Identitynumber

Dateofbirth

Postaladdress

Postalcode

Physicaladdress

Postalcode

Participant’soccupationorbusiness

Contactdetails

Telephonenumber(work)

Telephonenumber(home)

Telephonenumber(cell)

Faxnumber

EmailaddressZurichInsuranceCompanySouthAfricaLimited|15MarshallStreet,Ferreirasdorp,Johannesburg,2001|POBox61489,Marshalltown,2107|TelephoneNo.+27113709111|www.zurich.co.zaRegistrationNo.1965/006764/06|ZurichisanauthorisedFinancialServicesProviderNo.17703 1of18

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Co-participant

Firstname(s)

Surname

Identitynumber

Dateofbirth

Postaladdress

Postalcode

Co-participant’soccupationorbusiness

Contactdetails

Telephonenumber(work)

Telephonenumber(home)

Telephonenumber(cell)

Faxnumber

Emailaddress

Coverrequired

Effectivedate

Languagepreference English Afrikaans

GeneralInformation

Previouscover? Yes No

Ifyes,givefulldetails,i.e.nameofinsurer,policynumber,inceptionandcancellationdate(s)Hasanyinsurerevercancelled,declinedorrefusedtorenewyourcoverorimposedspecialterms? Yes No

Ifyes,givefulldetailsGivedetailsofalllossesorclaimssufferedinthelast3years(whethercoveredornot)

Typeofloss(fire,motor,accident,burglary,etc.) Year Amountpaid(approximate)Doyouintendgoingonholidaywithinthenexttwomonths? Yes No

Ifyes,givefulldetails

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Willthepremisesbeleftvacantforlongerthan60daysinanycalendaryear? Yes No

Ifyes,givefulldetails

Isthepremisesoccupiedduringtheday? Yes No

Ifyes,bywhom?Isanypartofthepremisesusedforbusinesspurposes? Yes No

Ifyes,givefulldetails

Isthepropertyisolated,e.g.onaplotoragriculturalholding(s)? Yes No

Ifyes,thePlotQuestionnaireistobecompleted

Pensionerinformation(tickappropriatebox)

Notapensioner Pensionerover55

Employedover50 Pensionerinaretirementvillage

Willthepremisesbeunoccupiedduringtheyear(tickappropriatebox)

Morethan60days 90days 120days 150days

180days 210days 240days 270days

300days

Buildings(Home)andHouseholdContentsSectionsInrespectofpropertytobecoveredpleasestate

Details Premises1 Premises2

Physicaladdress

Postalcode Postalcode

Construction Walls:Standardornon-standard

Roof:Standardornon-standardIfthatch,theQuestionnaireistobecompleted

Dwellingtype(pleasespecify) Clusterhome

Privatedwellinghome

Farmdwelling

Flat/apartment

Retirementvillage1

Simplex/duplex

Holidayhome

Townhouse

Parkhome

1Asecurecomplexorretirementvillagemeansacomplexwithhighperimeterwallswitheitherrazorcoilwireoranelectricfenceontopoftheperimeterwalls.Thecomplexmusteitherhavea24-hourstaffedsecuritygateoraccessmustbecontrolledbyan intercom,remotecontrolorregistrationatthegate.

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Details Premises1 Premises2

Occupiedbyyouas Owner Owner

Tenant Tenant

Securityprotectionsrequirements

Burglarbarsonallopeningwindows

Securitygatesonallopeningdoors

Alarmwitharmedresponse

Yes No Yes No Yes No Yes No Yes No Yes No

Ifyes,isamaintenancecontractinplace? Yes No Yes No

Nameofsecurityserviceprovider

Securecomplex/retirementvillage Yes No Yes No

Buildings(Home)Section

Building(Home)isdefinedastheprivateresidence,allgaragesandoutbuildings;brick,concreteortardriveways,pathsorpatios;walls,gatesandfences(otherthanhedges);tennisandsquashcourts;structureorfabricofswimmingpools,saunaorspabathsandboreholepumpssituatedattheaddressstatedintheschedule.

Financenoted(mortgagee)

Details Premises1 Premises2

Sumcovered R R

Optionalcover Maximumamountofcover

Accidentaldamagenototherwisecovered Yes No ROptional-MinimumR5,000;MaximumR100,000

Breakdownoffixedmachinery Yes No R

Optional-MinimumR5,000;MaximumR100,000

Additionalpowersurge(optionaltolimitedcover) Yes No R

Optional-MinimumR5,000;MaximumR100,000

Fullsubsidenceandlandslip Yes No R

(Geotechnicalreportrequired)

HouseholdContentsSectionThecompletionoftheinventoryformonthelastpageofthisapplicationwillassistinestablishingcorrectcurrentreplacementcostofcontents.

Details Premises1 Premises2

Sumcovered R R

Areyouentitledtoaclaimfreediscount? Yes No Yes No

Ifyes,namethecompanyandattachproofofdiscount

Businessfromhome Yes No Yes No

Limitedto35%ofsumcoveredlimitedtoR50,000

Optionalcover Maximumamountofcover

Accidentaldamagenototherwisecovered Yes No R

Optional-MinimumR5,000;MaximumR100,000

Electricalandmechanicalbreakdown Yes No R

Optional-MinimumR5,000;Maximum:R100,000

Additionalpowersurge(optionaltolimitedcover) Yes No ROptional-MinimumR5,000;MaximumR100,000

Subsidenceandlandslip Yes No R

(Geotechnicalreportrequired)

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SpecificItems(AllRisks)Section

Description Maximumamountofcover

Unspecified R

Specifieditems R

1. R

2. R

3. R

4. R

Notes

1.Attachvaluationcertificatesforitemssuchasspecifiedjewellery(exceedingR5,000)andincludephotographsifavailable.2.Whereapplicable,includeserialnumbersofspecifieditems.3.Describeitemsasfullyandaccuratelyaspossible.

PersonalComputerEquipmentSectionAddressofcomputerequipmentDescription Maximumamountofcover

Specifieditems R

1. R

2. R

3. R

4. R

Computersoftware Yes No R

Optionalcover

Reinstatementofdata(limitedtolaptopsanddesktops) Yes No R

MotorVehicleSectionDetails Vehicle1 Vehicle2

Yearofmanufacture

Makeandmodel

Mead&McGroutherCode

Maximumamountofcover(retailvalue) R R

Agreedvalue R R(specificvehiclecriteriaifagreed)

Typeofcover Comprehensive Comprehensive

Thirdparty,fireandtheft Thirdparty,fireandtheft

Thirdpartyonly Thirdpartyonly

Comprehensiveexcludingtheft Comprehensiveexcludingtheft

Classofuse A B C A B C

A.Privateand limitedprofessionalandbusinessuse:Social,domestic,pleasureandprofessionaluse, includingtravel toandfromyour homeandpermanentplaceofwork,studyorprofession.B.Private,professionalandfullbusinessuse:Social,domestic,pleasure,professionalandfullbusinessuse, includingtravel toandfrom yourhomeandpermanentplaceofwork,studyorprofession.

C.Privateuseonly:Social,domestic,pleasurepurposesonly.

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Details Vehicle1 Vehicle2

Registrationnumber

Vehicleidentificationnumber

Enginenumber

Financehouse

Claimfreegroup

Vehiclecolour

Overnightparking Carport Carport

Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking

Securityprotection Yes No Alarm Alarm

Gearlock Gearlock Immobiliser Immobiliser Trackingdevice Trackingdevice Recoveryidentification Recoveryidentification

Trackingdevice Yes NoIfyes,pleasegivethefollowingdetailsandprovidecertificate

Trackingdevicemakeandmodel

Trackingdeviceserialnumber

Trackingdeviceinstallationdate

Registeredownerdetails

Nameandsurname

Identitynumber

Principaldriverdetails

Nameandsurname

Identitynumber

Gender Male Female Male FemaleMaritalstatus Cohabitant Cohabitant

Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow

Additionaldriverterms

Additionaldrivers Yes No

Name,surnameandidentitynumber

1.

2.

3.

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Details Vehicle1 Vehicle2

Optionalcover Maximumamountofcover Maximumamountofcover

Vehicleaccessories(postmanufacturing)

Covered Yes No Yes No

Itemsdescription

Towbar Yes No R R

Leatherseats Yes No R R

Bluetooth Yes No R R

Creditshortfall Yes No R R(Comprehensivecoveronly)

Additionallocksandkeys Yes No R R

Excesswaiver Yes No R R

Voluntaryexcess Yes No R R

Additionalwreckageremoval Yes No R R

Additionalthirdpartyliability Yes No R R(MaximumlimituptoR10,000,000)

Optionalcoverextension

Carhire

Covered Yes No Days 30 45 Days 30 45

MotorCycleSectionDetails Cycle1 Cycle2

Yearofmanufacture

Makeandmodel

Mead&McGroutherCode

Maximumamountofcover(retailvalue) R RTypeofcover Comprehensive Comprehensive

Thirdparty,fireandtheft Thirdparty,fireandtheft

Thirdpartyonly Thirdpartyonly

Classofuse A B C A B C

A.Privateand limitedprofessionalandbusinessuse:Social,domestic,pleasureandprofessionaluse, includingtravel toandfromyour homeandpermanentplaceofwork,studyorprofession.B.Private,professionalandfullbusinessuse:Social,domestic,pleasure,professionalandfullbusinessuse, includingtravel toandfrom yourhomeandpermanentplaceofwork,studyorprofession.

C.Privateuseonly:Social,domestic,pleasurepurposesonly.

Enginecapacity

Importedormodified Yes No Yes No

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Details Cycle1 Cycle2

Registrationnumber

Vehicleidentificationnumber

Enginenumber

Financehouse

Claimfreegroup

Overnightparking Carport Carport

Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking

Registeredownerdetails

Nameandsurname

Identitynumber

Principaldriverdetails

Nameandsurname

Identitynumber

Gender Male Female Male Female

Maritalstatus Cohabitant Cohabitant

Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow

Additionaldriverterms

Additionaldrivers Yes No

Name,surnameandidentitynumber

1.

2.

3.

4.

5.

Optionalcover Maximumamountofcover Maximumamountofcover

Creditshortfall Yes No R R(Comprehensivecoveronly)

Additionallocksandkeys Yes No R R

Additionalwreckageremoval Yes No R R

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QuadsandOffRoadSection

Details Cycle1 Cycle2

Yearofmanufacture

Makeandmodel

Maximumamountofcover(retailvalue) R R

Typeofcover Comprehensive ComprehensiveClassofuse C C

C.Privateuseonly:Social,domestic,pleasurepurposesonly.

Enginecapacity

Importedormodified Yes No Yes No

Registrationnumber

Vehicleidentificationnumber

Enginenumber

Financialhouse

Overnightparking Carport Carport

Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking

Registeredownerdetails

Nameandsurname

Identitynumber

Principaldriverdetails

Nameandsurname

Identitynumber

Gender Male Female Male Female

Maritalstatus Cohabitant Cohabitant

Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow

Additionaldriverterms

Additionaldrivers Yes No Yes No

Name,surnameandidentitynumber

1.

2.

3.

4.

5.

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MotorisedRideOnEquipmentsuchasGolfcarts,SedgewayandRideOnLawnmowersSection

Details 1 2

Yearofmanufacture

Makeandmodel

Maximumamountofcover(retailvalue) R R

Typeofcover Comprehensive ComprehensiveClassofuse C C

C.Privateuseonly:Social,domestic,pleasurepurposesonly.

Enginecapacity

Importedormodified Yes No Yes No

Registrationnumber

Vehicleidentificationnumber

Enginenumber

Financehouse

Overnightparking Carport Carport

Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking

Registeredownerdetails

Nameandsurname

Identitynumber

Principaldriverdetails

Nameandsurname

Identitynumber

Gender Male Female Male Female

Maritalstatus Cohabitant Cohabitant

Divorced Divorced Married Married Single Single Separated Separated Widower Widower Widow Widow

Additionaldriverterms

Additionaldrivers Yes No Yes No

Name,surnameandidentitynumber

1.

2.

3.

4.

5.

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Caravan/TrailerSection

Details Caravan/Trailer1 Caravan/Trailer2

Yearofmanufacture

Makeandmodel

Maximumamountofcover(retailvalue) R R

Typeofcover Comprehensive Comprehensive

Thirdparty,fireandtheft Thirdparty,fireandtheft

Thirdpartyonly Thirdpartyonly

Classofuse A B C A B C

A.Privateand limitedprofessionalandbusinessuse:Social,domestic,pleasureandprofessionaluse, includingtravel toandfromyour homeandpermanentplaceofwork,studyorprofession.B.Private,professionalandfullbusinessuse:Social,domestic,pleasure,professionalandfullbusinessuse, includingtravel toandfrom yourhomeandpermanentplaceofwork,studyorprofession.

C.Privateuseonly:Social,domestic,pleasurepurposesonly.

Importedormodified Yes No Yes No

Registrationnumber

Vehicleidentificationnumber

Enginenumber

Financehouse

Claimfreegroup

Overnightparking Carport Carport

Lockedcarport Lockedcarport Lockupgarage Lockupgarage Behindlockedgates Behindlockedgates Intheopen Intheopen Secureparking Secureparking

Registeredownerdetails

Nameandsurname

Identitynumber

Optionalcover Maximumamountofcover Maximumamountofcover

Creditshortfall Yes No R R(Comprehensivecoveronly)

Additionallocksandkeys Yes No R R

Windscreen Yes No R R

PersonalLegalResponsibilitySectionCovered Maximumamountofcover

Personallegalresponsibility(Compulsory)

Yes No R2,500,000 R3,000,000 R4,000,000 R5,000,000

Optionalcover

Businessfromhome Yes No(included)

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ExtendedPersonalLegalResponsibilitySection

Covered Maximumamountofcover

Extendedpersonallegalresponsibility Yes No R10,000,000 R20,000,000

PersonalAccidentSectionCoveredperson

Nameandsurname

Identitynumber

(Dateofbirth/passportnumber)

Occupation

Specificcircumstancescovered Covered Maximumamountofcover

Death Yes No R

Permanenttotaldisablement(PTD) Yes No R

Temporarytotaldisablement(TTD)perweek

Yes No R

TTDnotexceeding104weeks Yes No R

Additionalmedicalexpenses(medicalcertificaterequired)

Yes No R

MotorPersonalAccidentSectionCovertype Anydriver Anypassengeranddriver Namedperson(s)

Ifnamedperson

Nameandsurname

Identitynumber

Yearofmanufacture

Makeandmodel

RegistrationnumberNumberofunits

Maximumamountofcover:Deathandpermanenttotaldisablement

Maximum amount of cover:Medicalexpenses

1. R250,000 R10,000

2. R500,000 R20,000

3. R750,000 R30,000

4. R1,000,000 R40,000

5. R1,250,000 R50,000

6. R1,500,000 R60,000

7. R1,750,000 R70,000

8. R2,000,000 R80,000

LegalCostsSection

Specificitemscovered Covered Maximumamountofcover

A R70,000

B R40,000Plantype

C R20,000 D R15,000

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WatercraftSectionVesselname

Vesseltype

Cruisingrange(Limited to South Africanterritorialwatersonly- Inlandwatersonly? Yes No

12nauticalmiles) Inlandandcoastalwaters? Yes No

Willthevesselbeusedoninlandwatersonly? Yes No

Ifno,Questionnaireistobecompleted.

Hullconstruction

Yearofmanufacturer

Vessellength

Unitofmeasure

Designspeed

Auxiliarymotors

Glitter

Claimfreegroup

Classofuse C

C.Privateuseonly:Social,domestic,pleasurepurposesonly.

Whatisyourboathandlingexperienceasaskipper?

Skippercertificate

Specificitemscovered Covered Maximumamountofcover

Hull Yes No R

Trailer Yes No R

Trailerdescription

Trailerregistrationnumber

Dinghy Yes No R

Auxiliarymotor(yachts) Yes No R

Specialequipment Yes No

Specialequipmentitemsdescription Maximumamountofcover

1. R

2. R

Inboard Yes No

Outboard Yes No

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Outboardmotordetails

Makeandmodel

Year

Serialnumber

Totalmaximumamountofcoverforwatercraftsection

R

Optionalextension Covered Maximumamountofcover

Roadorrailtransit Yes No R

Racingrisksails(yachtracing) Yes No R

Submergedobjects

Thirdpartyadditionalsumcovered(maximumlimituptoR750,000)Passengeradditionalsumcovered(maximumlimituptoR750,000)

Yes No R

Yes No R

Yes No R

Waterskiersextendedsumcovered Yes No R

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MonthlyDebitAuthority

Theinformationrequiredbelowistoenableyourmonthlycontributionstobedebitedfromyourbankaccount.Important:ifyouchangeyourbankaccountpleaseadvisetheCompanyimmediatelyandforwarddetailsofyournewaccount.

Intheeventthatthebankingdetailsbelowareinthenameofanotherperson,writtenconsentfromtheaccountholderisrequired.Intheeventthatthebankingdetailsbelowareinthenameofacompany,writtenconsent(fromthedirector)onthecompany’sletterheadandacancelledchequearerequired.

IherebydeclarethatZurichInsuranceCompanySouthAfricaLimitedisauthorisedtodebitthemonthlycontributionsfrommybankaccountstatedbelowandtoadjustsuchdebitasnecessaryduetochangesincover,risk,sumscoveredorcontributions.Nameofbank

Branchname

Branchnumber

Accountnumber

Nameofaccountholder

Typeofaccount

Shari’ahDeclaration

IagreetoparticipateintheTakafulWaqfFund“Fund”andthatmycontributionand/oranyinvestmentincomeoftheFund,shallbecreditedtotheFund.TakafulAfricaactingasTrusteesoftheFundhaveappointedZurichInsuranceCompanySouthAfricaLimitedtomanagetheFundinaccordancewiththerulesoftheFund.

IalsoagreethatmycontributionisanirrevocabledonationtotheTakafulWaqfFund.DeclarationConsenttoinformationsharingInsurersshareinformationwitheachotherregardingpoliciesandclaimswithaviewtopreventfraudulentclaimsandobtainmaterialinformationregardingtheassessmentofrisksproposedforinsurance.Byreducingtheincidenceoffraudandassessingrisksfairly,futurecontributionincreasesmaybelimited.Thisisdoneinthepublicinterestandintheinterestofallcurrentandpotentialparticipants.Thesharingofinformationincludes,butisnotlimitedto,informationsharingviatheInformationDataSharingSystemoperatedbyZurich’sserviceprovideronbehalfoftheSouthAfricanInsuranceAssociation.

Bythecompanyacceptingorrenewingthisagreement,youoranyotherpersonthatisrepresentedherein,giveconsenttothesaidinformationbeingdisclosedtoanyotherinsurancecompanyoritsagent.Youalsosimilarlygiveconsenttothesharingofinformationinregardtopastpoliciesandclaimsthatyouhavemade.Youalsoacknowledgethatinformationprovidedbyyourselforyourrepresentativemaybeverifiedagainstanylegallyrecognisedsourcesordatabases.Bycoveringorrenewingyouragreement,youherebynotonlyconsenttosuchinformationsharingbutalsowaiveanyrightsofconfidentialitywithregardtounderwritingorclaimsinformationthatyouhaveprovidedorthathasbeenprovidedbyanotherpersononyourbehalf.Intheeventofaclaim,theinformationyouhavesuppliedwithyourapplication,togetherwiththeinformationyousupplyinrelationtotheclaim,willbeincludedonthesystemandmadeavailabletootherinsurersparticipatingintheInformationDataSharingSystem.

Ideclarethattheinformationinthisapplicationis,tothebestofmyknowledgeandbelief,trueandaccurateineveryrespectandthatnofact,circumstanceorhazardthatcouldaffecttheacceptanceofmyapplicationhasbeenwithheld.IconfirmthatthisapplicationanddeclarationshallbethebasisofthisagreementbetweenTakafulAfrica,ZurichInsuranceCompanySouthAfricaLimitedandmyself.

Lastly,IalsoconfirmthatIwillnotbeabeneficiaryoftheTakafulWaqfFunduntilthisapplicationhasbeenacceptedandanycontributionsduehavebeenpaidinfull.

Signedat____________________________________________onthe__________dayof________________________20_____

Signatureofparticipant

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ContentsInventoryatNewReplacementValue

Bedroom 1 2 3 4

Mattresses

Bedsideradios

Tables,chairs,wardrobes

Curtains,loosecarpets

Paintings,ornaments

Linen,blankets,bedding

Clothing,footwear

Furs,jewellery

Lamps

ToysTVset,video,hi-fi

Other

TotalR

Study/workroomDesk,bookcases

Tables,chairs

Curtains,loosecarpets

Paintings,ornaments

Sewing,knittingmachine

Camera,projector

Firearms,binoculars

Typewriter,PC,faxmachine

Sportingequipment

Readinglamps

Other

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Bathroom/toilet 1 2

Curtains,loosecarpets

Towels,linen

Shavingequipment

Hairdryer

Toiletries

Other

TotalR

Passage/entryhallTables,chairs

Curtains,loosecarpets

Paintings,ornaments

Householdheaters

Linenstored

Other

TotalR

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LaundryWashingmachine

Tumbledrier

Iron,ironingboard

Curtains

Linenstored

Other

TotalR

LoungeLoungesuite

TV,video,videogames,DVDs

Hi-Fi/Tapedeck,CDplayer

Records,tapes,CDs,DVDs

Displaycabinet,articles

Curtains,loosecarpets

Paintings,ornaments

Readinglamps

Glassware

Other

TotalR

FamilyroomTV,video,videogames,DVD

Hi-Fi/Tapedeck,CDplayer

Records,tapes,CDs,DVDs

Tables,chairs

Curtains,loosecarpets

Paintings,ornaments

Furniture,chairs

Readinglamps

Glassware

Other

TotalR

DiningroomDresser,sideboard

Tables,chairs

Crockery,glassware

Cutlery,silverware

Linenstored

Readinglamps

Displayarticles

Hottray

Curtains,loosecarpets

Teatrolley

TotalR

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KitchenFridge/freezer

Dishwasher

Mixer,blender

Vacuumcleaner,polisher

Electricalappliances

Cutlery,crockery,glassware

Furniture,chairs

Groceries

Utensils

Microwaveoven

Other

TotalR

Garage/workshopPower/handtools

Workbench,vice

Bicycles

Lawnmover,roller

Gardenfurniture

Gardenimplements

Braaiequipment

Campingequipment

Swimmingpoolequipment

Weldingequipment

Other

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DomesticemployeeBed,mattress

Wardrobe

Tables,chairsCurtains,loosecarpets

Paintings,ornaments

Linen,blankets,bedding

Clothing,footwear

Radio,TV,video

Other

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GrandTotalR

AdditionalInformation/Comments

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