Policy Number:

Surname:*

Initials:

Title:

Your e-mail address:

Changes must take place on (date):*

New Postal Address line 1:

line 2:

line 3:

City:

Province:

Postal code:

New Telephone Numbers: - Home:

New Telephone Numbers: - Work:

Cellphone number:

New Risk Address is the same as the New Postal Address:

Yes

New Risk Address:line 1

New Risk Address:line 2

New Risk Address:line 3

City:

Province:

Postal code:

Construction material - roof:

Tiles
Tin
Thatch
Other

If Other, please give details:

Construction material - walls:

Bricks
Wood
Other

If Other, please give details:

Does the residence have any of the following Safety Precautions?

Burglar Bars in front of all windows that can open (And louvres)?

No
Yes

Safety Gates in front of all external doors (including sliding doors)?

No
Yes

Alarm linked to a control room?

No
Yes

Are the vehicles kept in a lock-up garage overnight?

No
Yes

Which cars are parked outside?

House Owner's Insurance Needed?

No
Yes

Amount R

Subsidence and Landslip (optional)

No
Yes

I hereby certify that the above information is correct.*

(Mark box)