Insurance - Welcome to Eazigear

APPLICANT NAME *

First

Last

(Must be South African Legal Entity)

EMAIL ADDRESS *

ENTITY *

PRIVATE
REGISTERED BUSINESS

BUSINESS REGISTRATION NUMBER: *

VAT NUMBER: *

COMPANY WEBSITE

ADDRESS WHERE EQUIPMENT IS STORED: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PHYSICAL PROTECTIONS AT THIS ADDRESS: *

Burglar Bars
CCTV record
All exterior doors have security gates
Alarm with armed response
Burglar bars in front of all windows

ANTICIPATED TYPE OF SHOOTS/EVENTS: *

Commercial
Feature
Documentary
Events
Own Use

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PERIOD OF INSURANCE REQUIRED: *

FROM

PERIOD OF INSURANCE REQUIRED: *

ROLE/DEPARTMENT OF APPLICANT: *

NUMBER OF YEARS IN BUSINESS: *

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ANTICIPATED TYPE PRODUCTIONS INSURED: *

EDUCATIONAL / TRAINING
FEATURE
DOCUMENTARY
COMMERCIAL
MUSIC VIDEO
TELEVISION DRAMA

Select where applicable

ANTICIPATED TYPE OF EVENT TO BE INSURED:

SEMINAR/ CONFERENCE
MUSIC FESTIVAL
SPORTING EVENT
FOOD/ LIFESTYLE
SCHOOL EVENT
MOTOR/ EXTREME SPORT

Select where applicable

HAS THE INSURED TRADED UNDER ANY OTHER COMPANY NAME DURING THE PAST 5 YEARS? *

IF YES, SUPPLY DETAILS

IS EQUIPMENT HIRED OUT TO ANY THIRD PARTY WHERE THE INSURED WILL NOT BE IN DIRECT CONTROL OF THE EQUIPMENT? *

WILL ANY EQUIPMENT BE USED FOR AERIAL OR UNDERWATER PHOTOGRAPHY? *

IF YES, SUPPLY DETAILS OF EQUIPMENT

DOES THE INSURED WORK OUTSIDE SOUTH AFRICAN BORDERS? *

IF YES, SUPPLY DETAILS

AVERAGE AMOUNT OF EVENTS / SHOOTS PER YEAR *

ANNUAL TURNOVER EXPECTED FOR PERIOD TO BE INSURED: *

You may base this on the last 12 months

AGGREGATED FREIGHT/ SHIPPING CHARGES *

What is this? This is additional Freight charges to repair insured items, in other words, how much you would be charged if you had to send your equipment overseas for repair work.
You can also include loss of income during this period.

DAILY RENTAL CHARGES *

ANY PREVIOUS CLAIMS IN THE LAST 5 YEARS? *

LIST ALL PREVIOUS CLAIMS FOR PAST 5 YEARS:

YEAR

VALUE

DESCRIPTION OF CLAIM

LIST ALL PREVIOUS CLAIMS FOR PAST 5 YEARS:

YEAR

VALUE

DESCRIPTION OF CLAIM

PLEASE UPLOAD A DETAILED LIST OF EQUIPMENT INCLUDING RAND VALUE TO BE INSURED *

Click or drag a file to this area to upload.

Format: PDF, Max 2MB

DECLARATION *

I have read, understand and agree with the terms below

Signing this application does not bind the applicant or the company to complete insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. If any of the above questions have been answered fraudulently, or in such a way to conceal or misrepresent material fact or circumstances concerning, this insurance or the subject thereof the entire policy shall be void.
I/We warrant that the answers given are true and correct. All details provided on this form are done so honestly and in good faith. This means that KEU Underwriting Managers (PTY) LTD has been made aware of all important information and that any incorrect information may mean that the claim may be rejected, and the policy cancelled. I/We have read the above and agree that to the best of my / our knowledge and belief it fully represents the true statements of facts.

I consent to KEU Underwriting Managers, Centriq and its operators, processing and further processing, my personal information in accordance with the Protective of Personal Information Act, for the purpose of concluding and performing in terms of this insurance contract.

For further information please read our Private Notice, which can be found on eazigear.com

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NAME OF BROKERING COMPANY

FSP NUMBER

SIGNATURE *

Clear Signature

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NAME OF INSURED *

DATE *

SIGNATURE *

Clear Signature

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