PROPOSAL FORM

GENERAL INFORMATION

Please tick ( ) the applicable block and provide full details where requested.

1. Where did you hear about Cyclesure?

Cycling publication Broker Friend Internet Brochure Cycle dealer

Date cover required from

2. Has any Insurer ever cancelled, declined or refused to renew your insurance or imposed special terms? Yes No

If Yes, give details:

3. Give details of ALL losses or claims suffered in the last 3 years ( whether cycling related, insured or not)

4. Who is your cycle dealer?

5. To which cycling club do you belong to?

6. Has your cycling equipment been insured previously ? Yes No

If yes, give details: Name of company and policy number

7. Where will the pedal cycle be stored when not in use ?

8. How do you transport your pedal cycle ?

9. If bike carrier is used, please name make & model

ADDITIONAL COVER

PEDAL CYCLE DETAILS

Name of cyclist using the following pedal cycle and accessories

ID number of cyclist

Type of pedal cycle: Road bike Mountain bike Time trial Track bike Tandem BMX

Purchased new Purchased secondhand

Make, model & size of frame Serial No. of frame Name of the fork

Gear ratio: 9sp 10sp 11sp

Saddle @ saddle pin

Shocks

Colour of frame

Groupset

Handelbars

Pedals

Wheelset

Total replacement value of the complete pedal cycle R

ACCESSORIES - (Please specify make and model)

YOU WILL HAVE TO CONSENT TO INFORMATION SHARING

Insurers share information with each other regarding policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. By reducing the incidence of fraud and assessing risks fairly, future premium increases may be limited. This is done in the public interest and in the interest of all current and potential policy holders The sharing of information includes, but is not limited to, information sharing via the information Data Sharing System operated by TransUnion ITC on behalf of the South African Insurance Association.

By the insurer accepting or renewing this insurance you are or any other person that is represented herein, give consent to the information being disclosed to any other insurance company or its agent. You also similarly give consent to the sharing of information in regards to past insurance policies and claims that you have made. You also acknowledge that information provided by yourself or your representative may be verified against any legally recognised sources or databases.

By insuring or renewing your insurance, you hereby not only consent to such information sharing but also waive any rights of confidentiality with regard to underwriting or claims information that you have provided or that has been provided by another person on your behalf. In the event of a claim, the information you have supplied with your application, together with the information you supply in relation to the claim, will be included on the system and made available to their insurers participating in the information Data Sharing System.

AND YOU WILL HAVE TO SIGN THIS DECLARATION BEFORE YOUR POLICY CAN BE ISSUED

I declare that the information in this application is, to the best of my knowledge and belief, true and accurate in every respect and that no fact, circumstance or hazard that could affect the acceptance of my application has been withheld. I confirm that this application and declaration shall be the basis of the contract between Cyclesure Insurance Consultants and myself.