FULL NEEDS ANALYSIS
PROSPECTIVE CLIENT TITLE
MR
MRS
MISS
MS
PROSPECTIVE CLIENT SURNAME
PROSPECTIVE CLIENT FIRST NAMES
PROSPECTIVE CLIENT I.D. NUMBER
CONTACT DETAILS (Wk/Hm/Cell)
MARITAL STATUS
Married
Unmarried
Living
Together
Divorced
Widow
Widower
OCCUPATION
(Please be specific)
EMAIL ADDRESS
PHYSICAL RISK ADDRESS DETAILS
POSTAL ADDRESS DETAILS
SHARING OF INSURANCE INFORMATION AND ITC CHECK:
In order for Risk Sure to accurately assess your risk, we require certain personal information from you. This information
enables us to obtain the necessary quotation/s on your behalf and we require your permission to share such information with
our recognized business partners. These business partners are bound by a non-disclosure undertaking to ensure the privacy
and confidentiality of the information you provide.
It is also important that you are made aware that certain business partners/insurers may wish to conduct a
mandatory ITC check in order to provide you with an accurate quote.
[YES]
Do we have your permission as required?
[NO]
GENERAL INFORMATION: (applicable to any member of your Household or any other person to be covered)
Have you or any member of your Household or any person to be covered:
[YES]
Been insured within the past 5 years?
If Yes, please provide the details:
[NO]
PREVIOUS INSURANCE
Insurer
Period of Insurance
Had any application for insurance declined; cancelled or renewal refused? [YES] [NO]
Had any special conditions imposed on any previous insurance policy?
[YES] [NO]
Been involved in any civil or criminal litigation in the past 3 years?
[YES] [NO]
Had a civil judgement imposed?
[YES] [NO]
Been convicted of any offence or have any prosecution pending?
[YES] [NO]
Had any claim repudiated by any Insurer?
[YES] [NO]
If Yes, please provide full details:________________________________________________________________
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[YES]
Had any claims in the past 5 years?
If Yes, please provide the details
[NO]
CLAIMS HISTORY: (applicable to any member of your Household or any other person to be covered)
Period
0-12 months
Type of Claim/Loss
Value of Claim/Loss
Insurer (if applicable)
12-24 months
24-36 months
36-48 months
48-60 months
Previous insurance history and details of previous claims OR losses in the last 5 years is an important rating factor. Even an
attempted burglary should be disclosed and failure to provide an accurate account of this information would constitute NonDisclosure and may result in the repudiation of a claim by the Insurer.
MATERIAL INFORMATION / DISCLOSURE:
Please disclose any other relevant information that you think may affect your risk. Disclosure of all related facts is
critical at the point of quote to ensure that the correct cover is arranged in order to eliminate any possible claim
repudiation in the future.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONFIRMATION OF YOUR IMMEDIATE SHORT TERM INSURANCE REQUIREMENTS:
Please indicate what your specific requirements/intentions are in requesting our assistance with your Short Term Insurance
needs:
Please note that if a comprehensive analysis is NOT required there may be limitations on the appropriateness of
advice provided to you. You will then need to be responsible for considering whether your objectives, financial
situation and particular needs have been adequately met by any alternative cover offered to you.
CURRENTLY INSURED: Looking for a cheaper alternative – NO ADVICE REQUIRED (Covers as
detailed in this Needs Analysis)
CURRENTLY INSURED: Looking for a cheaper alternative - ADVICE REQUIRED (Cover as detailed
in this Needs Analysis plus any recommendations offered)
NO PREVIOUS INSURANCE: Require Comprehensive ADVICE
NO PREVIOUS INSURANCE: Do not require comprehensive ADVICE
OTHER:
FULL LIST OF AVAILABLE COVERS: (Differs from Insurer to Insurer)
The below table can be used a COVER GUIDELINE. It will provide you with information pertaining to what
covers are available to you and can be referred to by you as you complete this Needs Analysis. Should you require
our assistance in clarifying any of the below listed covers, please do not hesitate to ask.
SELECTABLE POLICY SECTIONS:House Owners (Domestic Buildings)
Optional Covers:
- Accidental Damage
- Power Surge
House Holders (Domestic Contents)
Optional Cover:
- Accidental Damage & Power Surge
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Personal Accident Cover:
The intense media attention and debate surrounding the Road Accident Fund limitations which are resulting in
South Africans facing increased exposure in the event of death or disability following a road accident, may
prompt you to take this cover
All Risk Cover:
 General - Clothing and personal effects
 Personal Money Cover
 Specified – Jewellery, sunglasses, prescription glasses, contact lenses, pedal cycles, cellular
phones, audio equipment, stamps and coin collections, contents of a caravan etc
Motor (Domestic Vehicles) - Comprehensive/TPF&F/TPO
Optional Cover:
- Excess Waiver Benefit
- Car Hire (30/60/90 days with choice of hired vehicle)
- Credit Shortfall (‘top up cover’)
Motor Cycle (Domestic & Recreational Use)
Trailer
Caravan
Pleasure Craft (watercraft)
Personal Computer & Appurtenances (desktop/laptop/notebook/IPAD)
Personal Computer Software
Legal Cost (arising out of civil litigation)
Extended Personal Legal Liability Cover
Bereavement expenses
Hospital Cash Plan
Mechanical and Electrical breakdown
Premium Waiver for Retrenchment or Redundancy
Identity Theft Cover
Home Employers’ Labour Dispute Cover
COMPULSORY COVERS:
Personal Liability (R5 000 000)
SASRIA (Riot Cover)
The following questions are in respect of your main residence: (please duplicate this document if insurance is required for
more than one risk address)
Regardless of cover being taken, it is compulsory to answer the following questions:
ROOF CONSTRUCTION
Tile
Concrete
Shingles
Fibre Cement
Slate
Metal
Thatch
Other
______________________
WALL CONTRUCTION
Brick/stone/Concrete
Asbestos
Metal Frame & Fibreglass
Timber/Part Timber Framed
Prefabricated Sandwich Panels
Other
_______________________
WHAT TYPE OF HOME DO YOU HAVE
Detached house/Cottage
Semi Detached house/Cottage
Cottage
Apartment / Flat (ground or first floor)
Apartment / Flat (above 1st floor)
SITUATION OF RESIDENCE
Smallholding / plot / farm
Security village / Complex
Retirement Complex
Enclosed Access Controlled Area
Residential Area, No Access Control
WHAT TYPE OF GEYSER DO YOU HAVE
Standard
Solar
Other
_______________________
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ARE ANY OF THE FOLLOWING WITHIN 500m OF THE RESIDENCE?
Shoreline/River/Lake or Dam
[YES] [NO]
GENERAL OCCUPATION
Will the residence be left unoccupied (>7 days) within the first 30 days [YES] [NO]
Will the residence be left unoccupied during working hours
[YES] [NO]
Will the residence be left unoccupied for >60 days per annum
[YES] [NO]
Will the residence be used as a holiday home
[YES] [NO]
Will the residence be hired or let out
[YES] [NO]
If yes, please supply details of hire/letting arrangement___________________________
SECURITY
WINDOWS - Single Storey Residence:
Are all ground floor opening windows (including louvers) barred
[YES] [NO]
The above is a basic requirement of THEFT/BURGLARY Cover. Additional requirements may be imposed by the
Insurer and any such requirement will be advised to you and will be reflected on your quote.
WINDOWS – Multi Storey Residence:
Are all the opening windows (including louvers) burglar barred
[YES] [NO]
The above is a basic requirement of THEFT/BURGLARY Cover. Additional requirements may be imposed by the
Insurer and any such requirement will be advised to you and will be reflected on your quote.
DOORS:
Are all access doors fitted with security gates
Does any outbuilding/garage adjoining the main residence have an
Inter-leading door
[YES]
[NO]
[YES]
[NO]
GATES/FENCING:
Is the perimeter of the property walled/fenced with a wall or steel fence
of at least 1.8 m in height
[YES]
Is there razor/barbed wire/fence on the perimeter wall/fence
[YES]
If Yes, please indicate as follows:
Some perimeter walls/fence have razor/barbed wire/electric fencing
All perimeter walls/fence have razor/barbed wire/electric fencing
Are there full time security guards on your property
[YES]
Is there 24hour access control to your property
[YES]
Does your home have an alarm
[YES]
If Yes, please specify the armed response company________________
HOUSEHOLD CONTENTS COVER:
Do you require this cover?
[YES]
[NO]
[NO]
[NO]
[NO]
[NO]
[NO]
VALUE OF CONTENTS:
(Insure for New Replacement
Value)
Cover Option:
Full Cover
Limited Cover
Comprehensive
Burglary excluded
OPTIONAL COVER: (At an additional premium)
Extended Accidental Damage including Power Surge –
If you require this cover please select the limit required:
R 10 000
R 25 000
R 50 000
R100 000
In respect of Contents Cover Please Note:
 Under insurance will be prejudicial to you should you have to make a claim so please make sure that your
sum insured adequately covers your assets. Should you be found to be underinsured at the time of a claim,
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the principle of Average will apply. To use an example by way of explanation, should the sum insured
reflected in the schedule be 70% of the actual replacement cost of all the household contents, then only
70% of the amount of the claim will be paid by the Insurer. Hence the importance of adequately insuring
your assets!

There is limited cover under the Household Goods Section for items of jewellery, furs, rugs and carpets, precious
metals and stones. Cover is limited to one-third of the Household Goods Sum Insured provided that the sum
insured is adequate and that under-insurance is not a consideration. It is for this reason that we recommend that
items of value be specifically insured under the All Risk Section of the policy where cover is Comprehensive and
Worldwide.
BUILDING COVER: Calculation based on current re-building cost per m²
Do you require this cover?
[YES] [NO]
VALUE OF BUILDING:
(Insure Buildings and Outbuildings
for New Replacement Value)
OPTIONAL COVER: (At an additional premium)
Accidental Damage to fixed machinery used in your home –
If you require this cover please select the limit required:
R 10 000
R 25 000
R 50 000
R100 000
Power Surge –
If you require this cover please select the limit required:
R 10 000
R 25 000
R 50 000
R100 000
In respect of Building Cover Please Note:
 Under insurance will be prejudicial to you should you have to make a claim so please make sure that your
sum insured adequately covers your assets. Should you be found to be underinsured at the time of a claim,
the principle of Average will apply. To use an example by way of explanation, should the sum insured
reflected in the schedule be 70% of the actual replacement cost of all the household contents, then only
70% of the amount of the claim will be paid by the Insurer. Hence the importance of adequately insuring
your assets!
GENERAL ALL RISK COVER
Do you require this cover?
[YES]
[NO]
GENERAL ALL RISK SUM INSURED:
In respect of All Risk Cover Please Note:
 General Unspecified All Risks (personal effects normally worn or designed to be carried on or by the person):
Please note, any one item is limited to 25% of the sum insured and certain items such as contact lenses, pedal
cycles, cellular phones, money, stamp and coin collections and the contents of caravans are excluded (please refer
to the policy wording for a more detailed description of what is covered);

Please note, loss from an unattended vehicle is not covered unless the property is contained in a completely
closed and securely locked vehicle. Do not leave things in sight!

In the event of any claim under the General or Specified All Risk section, the Insurer reserves the right to repair
or replace (via one of their suppliers) such item.
SPECIFIED ALL RISK COVER
Do you require this cover?
[YES]
[NO]
In respect of SPECIFIED All Risk Cover Please Note:
Certain items cannot be claimed for under the General All Risk Section and therefore need to be specifically insured.
Such items include, but are not limited to:
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






Mobile communication devices such as cell phones; iPads, iPods, Note Books, Car Radios
Bicycles, surf boards, kite boards, paddle skis, kayaks, canoes, surf skis, windsurfers and sailboards
Tools
Stamp and coin collections
Money and Documents
Furs and leather jackets
Wheelchairs
Guns
IF COVER REQUIRED, Please specify All Risk Items and Values:
1._____________________________________
2.______________________________________
3._____________________________________
4.______________________________________
5._____________________________________
6.______________________________________
MOTOR:
Do you require this cover?
[YES]
[NO]
Motor Cover Types:
***Comprehensive Cover: Total Loss, Theft, Own Damage, Third Party Damage Included
***Third Party Fire and Theft: Third Party, Fire and Theft Included – Own Damage excluded
***Third Party Only: No cover other than cover i/r/o Third Party
IF YES, Please provide the following information:
Vehicle 1
Cover Type (See list above***)
Make of Vehicle
Model of Vehicle (please be specific)
Year of Manufacture
Manual or Automatic
Vehicle colour
Is the paint Metallic
Value of Extras
Vehicle Finance Details
TOP UP COVER: The difference
between the outstanding finance
amount and the Insurers
Compensation Limit
If required, please state the amount
Total Value Inclusive of Extras and
Top Up Cover if applicable
Daytime parking Suburb
Daytime parking security: (tick)
No access control & no security guard
Access control & security guard
Access control and no security guard
Security guard with no access control
Locked garage/behind locked gates
Full Night Time parking address: (if
not the main risk address)
Night time parking security: (tick)
No access control & no security guard
Access control & security guard
Access control & no security guard
Security guard with no access control
Locked garage/behind locked gates
Vehicle 2
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Vehicle 3
Vehicle 4
Registered Owner
Regular Driver
If Regular Driver other than Owner,
please specify relationship to owner
Regular Driver ID No.
Regular Driver’s Marital Status
Regular Driver Date of First Licensing
Driver’s License Code
Any License Restrictions (if yes please
provide details)
Regular Driver’s Occupation
Any special needs due to a physical
disability (applicable to anyone who
may drive the vehicle at any time)
VEHICLE USE
Please specify Domestic/Business Use
Optional Cover: (Additional cost)
Excess Waiver (Drivers over 30)
Car Hire:
Selectable: 30/60/90 days
Selectable: 1300/1600/2.0
The two descriptions and their purposes are:
1 Domestic Use: Social, private, recreational, travel to & from
work
2 Business Use: Business travel (excluding commercial use)
including domestic use as noted above
NOT APPLICABLE TO MOTOR CYCLES/TRAILERS/CARAVANS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
OFFICE USE ONLY: Details Required on ACCEPTANCE of Proposed Cover
Registration Number
Engine Number
VIN (Chassis) Number
M&M Code
WOULD YOU LIKE TO CONSIDER A VOLUNTARY MOTOR EXCESS:
[YES] [NO]
This selection overrides the Standard Basic Excess (differs from Insurer to Insurer) and is useful to achieve a
reduced premium however, caution must be exercised so as to avoid disappointment at the time of a claim as any
own damage loss/damage that occurs will be subject to the voluntary excess and as it is higher than the standard
excess it is more likely that minor damage claims may fall within the excess (your portion of the claim) resulting in
“No Claim” for your own loss/damage. Please consider this carefully prior to your selection: (mark with X)
R3000
R4000
R5000
R6000
PREVIOUS INSURANCE HISTORY/CLAIMS OF DRIVER/s: Last 5 years (Required if DRIVER/s differs from
Policy Holder)
Insurer
Period of Insurance
Relevant Claims information
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OTHER COVERS:
ADDITIONAL COVERS TO BE
CONSIDERED/REQUIRED
If required and where applicable please
provide description and value or note
that you are interested in such cover
Personal Accident Cover:
Motor Cycle (Domestic & Recreational Use)
Trailer
Caravan
Pleasure Craft (watercraft)
Personal Computer & Appurtenances
(desktop/laptop/notebook/IPAD)
Personal Computer Software
Legal Cost (arising out of civil litigation)
Extended Personal Legal Liability Cover
Bereavement expenses
Hospital Cash Plan
Mechanical and Electrical breakdown
Premium Waiver for Retrenchment/Redundancy
Identity Theft Cover
Home Employers’ Labour Dispute Cover
Other?
DECLARATION:
I, the Undersigned, declare that the above information provided by me is true and correct. I understand that any quote
provided is valid for 30 days and subject to the acceptance of the Underwriter on completion of a Proposal form or signed
quotation. Should any information change, I understand that this may have an effect on the quoted premium.
I also confirm that the Risk Sure Consultant has confirmed that the relevant Financial Service Provider(s) Disclosure Notice(s)
will be provided to me should I accept any quote provided. Such notice(s) will provide important information such as, but not
limited to:
 Details about the Financial Service Provider;
 Details regarding the Mandate that the FSP has with the various Insurers;
 Details of the FSP’s FSB approved Representatives and Key Individuals;
 Details confirming that the FSP accepts responsibility for the financial services rendered by its Representatives performed
within the scope of their employment;
 Details confirming that the FSP has Professional Indemnity Cover
 Details regarding the Commission earned by the FSP;
 Details on the collection of premium and consequences of non-payment
 Details on how to institute a claim;
 Details about the FSP’s Compliance Officer;
 Details of the Compliance Officer in respect of SASRIA cover;
 Details on the Ombudsman for Short Term Insurance;
 Details on the Registrar for Short Term Insurance;
To be signed by the prospective client only once ALL information has been completed .
DATED:
Year ___________________________________
OFFICE USE:
Risk Sure Consultant :__________________
Date
:__________________
Month __________________________________
Day ____________________________________
I hereby confirm that the abovementioned information (pages 1-8) is true and correct.
(Prospective Client Signature) ______________________________________________________
BLANK OR INCOMPLETE FORMS MUST NOT BE SIGNED!!!
PLEASE MAKE A COPY OF THIS COMPLETED DOCUMENT FOR YOUR OWN RECORDS
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