Quotation for Insurance with Alexander Forbes Insurance Company

Quotation for Insurance with Alexander Forbes Insurance CompanyClient NameID:Tel Cell FaxE-mailOccupationAffinity Referred by AF Employee NoInsurer(s) - last 3 yrs From ToLoss History last 3 years (whether insured or not)Date Cause of loss Value RecoveryRisks DetailStreetSuburbTown CodeRisk 1Risk 2Risk 1Burglar bars Alarm + response Electric fenceSecurity complexNameConstructionResidential typeRoof WallsSubsidence & landslipThatch lapam²Risk 2Burglar bars Alarm + response Electric fenceSecurity complexNameConstructionResidential typeRoof WallsSubsidence & landslipThatched lapam²Buildings Contents Buildings ContentsRisk 1 Risk1 Risk 2 Risk2Cover optionSum InsuredR R R RVol excessR R R RUnoccupied more than 60 days a yearWater leakageRRAll RisksUnspecified clothing & effectsSpecified ItemsSports Equipment R RPedal cycle R RTapes & CD's R RCell phones 1) R R2) R R3) R RCar sound equipment 1) R R2) R R3) R RVoluntary excessRIssue: September 2008 Page 1 of 2

MOTOR Vehicle 1 Vehicle 2Residential AddressMakeModelYearFirst reg. DateCoverRegistration nrChassis nrCredit shortfallCar hire60 days Equiv. 60 days Equiv.Vol. ExcessRRVSS compliantVESA alarm immobiliserVESA approved Gear lockVESA approved TrackingFemale driverAdvance driverLimited mileage Km KmInsured is registered ownerDrivers nameDrivers D.O.BUseMileageKmKmConditionAccessoriesRRDate of drivers 1st licenseOptional CoverPleasure CraftLegal CostExtended Personal LiabilityIdentity TheftAdditional InformationNotesYour NameTelFaxMobileE-mailAFI SANDTONP.O. Box 786053, Sandton, 2146Alexander Forbes Place90 Rivonia RoadSANDTON 2196Issue: September 2008 Page 2 of 2