Business Vehicle Protect – InsureEasy Brokers

How are you completing this application?

Select one option before continuing.

Self Service I am completing this application myself.

Agent Assisted An InsureEasy representative is helping me complete this application.

Verify Representative

Enter the representative's registered cellphone number.

Representative —

Registered Cell —

Cover

Vehicles

Policyholder

Risk

Debit Order

Review

Step 1 of 6

Vehicle Cover

Select the number of vehicles and the cover required for each vehicle.

Important: The premium displayed is indicative. The application is subject to underwriting assessment and acceptance before cover can commence.

Number of Vehicles *

Indicative Total Monthly Premium R0.00 The same tariff applies to individual and business policyholders. Final acceptance remains subject to underwriting.

Step 2 of 6

Vehicle Details

Enter the identifying information for each vehicle included in this application.

Step 3 of 6

Policyholder & Insurance History

Tell us who will hold the policy and provide the underwriting information.

Policyholder Type *

Policyholder / Owner Full Name *

ID / Passport Number *

Capacity *

Cellphone Number *

Email Address *

Residential / Physical Address *

Copy of Policyholder / Owner ID * For a business application, upload the ID of the owner, director, member or authorised person completing the application.

Previous Insurance *

Time With Previous Insurer

Has an insurer ever cancelled your insurance? *

Have special terms or conditions ever been imposed? *

Step 4 of 6

Risk Details

Provide the business information where applicable and the address where the insured vehicle is normally kept.

Business / Entity Name *

Company Registration Number

Industry Type *

Business Telephone / Cellphone *

Business Email

Business Description / Activity *

Risk / Garaging Address * Address where the vehicle is normally kept overnight.

Province *

Postal Code

Step 5 of 6

Payment Method

Choose a debit-order mandate, pay online now, or choose a date for a payment reminder.

A. Bank Debit OrderProvide bank details and sign the debit-order mandate. B. Paystack — Pay NowAfter submitting, continue to InsureEasy PayEasy for online payment. C. Paystack — Pay LaterChoose a date. We will remind you to complete payment through PayEasy.

Completing the debit-order mandate does not activate cover or trigger an immediate debit. The mandate is supplied as part of the application for processing following underwriting acceptance.

Banking Details

Enter the account from which the monthly premium may be collected.

Is the policyholder also the account holder? *

Account Holder *

Bank *

Branch Code *

Account Type *

Account Number *

Preferred Monthly Debit Date *

Mandate Signed At *

I authorise InsureEasy Brokers and/or its authorised agents and/or cessionary to draw against the bank account provided the amount payable in terms of the insurance agreement.

I understand that cancellation of the debit-order authority does not automatically cancel the insurance agreement.

Account Holder Signature *

Account holder signs here

Signature required

Step 6 of 6

Review & Submit

Review the application and submit it for underwriting assessment.

Policyholder Type —

Policyholder —

Business / Entity —

Number of Vehicles —

Indicative Monthly Premium —

Payment Method —

Application Channel —

Representative —

Motor excess: Own Damage, Theft/Hijack and Cosmetic Damage are subject to the applicable excess. Glass and Third-Party Liability remain subject to the applicable policy wording.

I understand the selected sums insured and benefit limits.

I understand the applicable motor excesses.

I understand that claims remain subject to the policy terms, exclusions and supporting documentation.

I understand that Sasria cover is subject to the applicable Sasria terms and schedule.

I consent to the processing and authorised sharing of information required for underwriting, policy administration, premium collection and claims.

I understand that this application is subject to underwriting and that submitting the application does not mean cover has commenced.

I confirm that the information supplied is true and complete.

Policyholder Signature *

Sign here using your finger, mouse or stylus

Signature required

What happens next? Your Vehicle Protect application will be recorded in InsureEasy's application system and prepared for underwriting assessment. Cover has not commenced at this stage.

InsureEasy Brokers

Phone Number

Contact Address

Email Address

Vehicle Protect

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