Reference Number: zphni
| Consent to POPIA | |
|---|---|
| CONSENT TO PROCESS PERSONAL INFORMATION IN TERMS OF THE PROTECTION OF PERSONAL INFORMATION ACT, NO. 4 OF 2013 (POPIA) The Protection of Personal Information Act 4 of 2013 (“POPIA”) is South Africa’s Data protection law. It was created to give effect to the Constitutional right to privacy and protect the use of private information. We will be collecting your personal information to enable us to fulfil the mandate that we have been given by you. |
|
|
I, Ariana Jacpasad, a natural person (Data Subject) with ID no.: 0205130174555.
hereby give my consent to ProVérte Risk Management (Pty) Ltd (The Responsible Party) to collect, process and where legally required, distribute my personal information in accordance with the provisions of POPIA.
This consent will remain effective until such consent is withdrawn.
|
|
|
Signed at_______________________________________________________________________________________ this ___________ day of _____________ 20_______________. Name + Surname of Responsible Party (Employee of ProVérte): _______________________________________________________________________________________ Signature: _____________________________________ |
|
| I have read and consent to the POPIA Compliance Policy and I have signed the consent form. | Yes |
| To enable the insurers to underwrite risk fairly and to combat insurance fraud, we need to have your consent to verify and share policy information with insurers and other institutions as well as to access credit information held by other institutions. Do you give consent? | Yes |
| Personal Information | |
|---|---|
| Full name & Surname: | AJ Jax |
| ID no. | 0306140574523 |
| Passport no. | Nationality: DOB: |
| Marital Status | |
| Occupation | unemployed |
| Telephone Number: | 0843424083 |
| Email Address | arianajacpasad@gmail.com |
| Address Information | |
| Postal Address | , , |
| Insurance History | |
| Are you currently insured or did you have any previous Insurance – Yes or No | |
| Details of previous insurance | Comapany: Ariana Company Policy Number: |
| Has any insurer / underwriter ever cancelled/declined/refused to renew/impose special terms or conditions or any policy held by you | Yes If yes – |
| Any losses in the last 5 years: | Yes |
| Buildings/Contents Cover | |
| Contents – Security Measures | |
| Security Perimeter | Yes |
| Security Area | No |
| Security at the property (House) | Yes |
| Personal All Risk Cover | |
| Unspecified All Risk Insured Amount | |
| Personal Accident Cover | |
| Watercraft Cover | |
| permission to the insurers to share policy information and to perform a credit check with various credit bureaus to enable them to do proper underwriting and prepare a quotation. | Yes |
| Signature |  |
| Date of Signing | September 17, 2025 |
Reference Number: dyhjz
| Consent to POPIA | |
|---|---|
| CONSENT TO PROCESS PERSONAL INFORMATION IN TERMS OF THE PROTECTION OF PERSONAL INFORMATION ACT, NO. 4 OF 2013 (POPIA) The Protection of Personal Information Act 4 of 2013 (“POPIA”) is South Africa’s Data protection law. It was created to give effect to the Constitutional right to privacy and protect the use of private information. We will be collecting your personal information to enable us to fulfil the mandate that we have been given by you. |
|
|
I, , a natural person (Data Subject) with ID no.: .
hereby give my consent to ProVérte Risk Management (Pty) Ltd (The Responsible Party) to collect, process and where legally required, distribute my personal information in accordance with the provisions of POPIA.
This consent will remain effective until such consent is withdrawn.
|
|
|
Signed at_______________________________________________________________________________________ this ___________ day of _____________ 20_______________. Name + Surname of Responsible Party (Employee of ProVérte): _______________________________________________________________________________________ Signature: _____________________________________ |
|
| I have read and consent to the POPIA Compliance Policy and I have signed the consent form. | Yes |
| To enable the insurers to underwrite risk fairly and to combat insurance fraud, we need to have your consent to verify and share policy information with insurers and other institutions as well as to access credit information held by other institutions. Do you give consent? | No |
| Personal Information | |
|---|---|
| Full name & Surname: | MM Singleton |
| ID no. | 9410010041087 |
| Passport no. | Nationality: DOB: |
| Marital Status | |
| Occupation | |
| Telephone Number: | |
| Email Address | |
| Address Information | |
| Postal Address | , , |
| Insurance History | |
| Are you currently insured or did you have any previous Insurance – Yes or No | |
| Details of previous insurance | Comapany: Policy Number: |
| Has any insurer / underwriter ever cancelled/declined/refused to renew/impose special terms or conditions or any policy held by you | Yes If yes – |
| Any losses in the last 5 years: | |
| Buildings/Contents Cover | |
| Contents – Security Measures | |
| Security Perimeter | No |
| Security Area | Yes |
| Security at the property (House) | |
| Personal All Risk Cover | |
| Unspecified All Risk Insured Amount | |
| Personal Accident Cover | |
| Watercraft Cover | |
| permission to the insurers to share policy information and to perform a credit check with various credit bureaus to enable them to do proper underwriting and prepare a quotation. | Yes |
| Signature |  |
| Date of Signing |
Reference Number: wmslb
| Consent to POPIA | |
|---|---|
| CONSENT TO PROCESS PERSONAL INFORMATION IN TERMS OF THE PROTECTION OF PERSONAL INFORMATION ACT, NO. 4 OF 2013 (POPIA) The Protection of Personal Information Act 4 of 2013 (“POPIA”) is South Africa’s Data protection law. It was created to give effect to the Constitutional right to privacy and protect the use of private information. We will be collecting your personal information to enable us to fulfil the mandate that we have been given by you. |
|
|
I, Ariana Jacpasad, a natural person (Data Subject) with ID no.: 0843342408312.
hereby give my consent to ProVérte Risk Management (Pty) Ltd (The Responsible Party) to collect, process and where legally required, distribute my personal information in accordance with the provisions of POPIA.
This consent will remain effective until such consent is withdrawn.
|
|
|
Signed at_______________________________________________________________________________________ this ___________ day of _____________ 20_______________. Name + Surname of Responsible Party (Employee of ProVérte): _______________________________________________________________________________________ Signature: _____________________________________ |
|
| I have read and consent to the POPIA Compliance Policy and I have signed the consent form. | Yes |
| To enable the insurers to underwrite risk fairly and to combat insurance fraud, we need to have your consent to verify and share policy information with insurers and other institutions as well as to access credit information held by other institutions. Do you give consent? | Yes |
| Personal Information | |
|---|---|
| Full name & Surname: | Ariana Jax |
| ID no. | 0306140574523 |
| Passport no. | Nationality: DOB: |
| Marital Status | Divorced |
| Occupation | unemployed |
| Telephone Number: | 0843424083 |
| Email Address | arianajacpasad@gmail.com |
| Address Information | |
| Postal Address | Test test line 2 Cape Town, Western Cape, 7130 |
| Insurance History | |
| Are you currently insured or did you have any previous Insurance – Yes or No | Yes |
| Details of previous insurance | Comapany: Ariana Company Policy Number: n/a |
| Has any insurer / underwriter ever cancelled/declined/refused to renew/impose special terms or conditions or any policy held by you | Yes If yes – Broke |
| Any losses in the last 5 years: | Yes |
| Losses: | Year: 2023 Damage/Claim amt: 39000000 Description of loss: broken, broken, gone, gone, broken, broken, broken |
| Buildings/Contents Cover | Yes |
| Address: | test street, test line 2, Cape Town,Western Cape, 7130 |
| Contents & Buildings or Both: | Contents, Building |
| Contents Insured amt | Contents: 36000 Buildings: 451202 |
| Buildings Cover | |
| Will you rent out this dwelling from time to time | Yes |
| If Yes – |
broken, broken, gone, gone, broken, broken, broken |
| Is Building financed | Yes |
| Bond holder details | Bank name: Absa Account Name: R5350 Melee Type: Dual Chain Expiry Date: October 24, 2025 |
| Accidental damage to fixed machinery cover? Yes |
Accidental damage to fixed machinery Insured Amount: 2125457 |
| Power surge cover? Yes |
Power Surge Insured Amount: 1021554 |
| Geyser Maintenance Yes |
Maintenance Amount: R5 000 |
| Building Address | building address. building address 2, Cape Town, Western Cape, 7130 |
| Premise Use | Main Residence |
| Dwelling type | Flat / Apartment – Ground Floor |
| Informal settlements or building activities within 2km from main dwelling | Yes |
| Is the dwelling within 100m of the following: | |
| River, dam, lagoon, or any other water source (natural or man-made) | |
| Previous flood related losses in the past | If yes- broken, broken, gone, gone, broken, broken, broken |
| Who occupies the dwelling: | |
| Will the residence be used for: | broken, broken, gone, gone, broken, broken, broken |
| Roof & Wall Construction | |
| Roof | Thatch |
| Underwriting questions related to thatch roofs & lapa’s | Clients Name: ari Policy Number: 123456 |
Address: | 123 Internet Road | SABS or NSI compliant lightning conductor installed at the premises? | Yes | Is the thatched roof protected by a fire blanket? | Yes | – If yes, only some part or entire thatch roof? | Entire | Is the thatched roof protected by Thatch-Sayf or Thatch-guard? | Yes | Does the kitchen have a concrete ceiling? | Yes | Is a 4,5kg fire extinguisher installed in each kitchen of the private home? | Yes | Is there a fire hose reel installed in each kitchen of the private home? | No | If not, do you have a fire hose outside? | No | – If not, do you have a fire house outside? | Yes | Do you have open fires in the private home? | Yes | – If yes, is the chimney flue made of brick? | Yes | – If yes, are there spark arrestors installed inside the chimney flue? | Yes | Metal Chimney through thatch roof? | Yes | Brick Chimney through thatch roof? | Flash Plate between chimney and roof? | Yes | Distance from fire brigade: | 30 km | Thatched roof protected by a drencher system | Yes | – If yes, manual or automatic | Auto | Thatched roof protected by a sprinkler system? | Yes | Thatch Roof Area Size | ≤ 250m² | Thatch Roof last maintained, combed or replaced within the last 5 years? | Yes | Ridge Plate | New Option |
| Do you use LP gas inside the residence | Yes |
| – If yes, is LP gas bottle inside exceeding 19kg | Yes |
| Lapa Classification | Smaller than 50m² and closer than 4 meters from dwelling | Yes | Larger than 50m² or larger than 15% of roof area and closer than 4 meters from dwelling | Yes | Further than 4 meters away from dwelling | Yes | October 22, 2025 |  |
| Walls | Other (Please specify) |
| Will the dwelling be unoccupied for more than 60 days per year | Yes |
| Will the dwelling be left unoccupied for more than 7 days within the 1st 30-days of cover? | Yes |
| Contents – Security Measures | |
| Security Perimeter | Residence perimeter wall of brick / palisades / vibacrete, Outer perimeter wall (complex/estate) of brick / palisades / vibacrete, Electric fencing nog linked, Electric fencing linked with no armed response, Electric fencing linked with armed response, Remote Access Contral, Guard patrolling with no armed response |
| Security Area | Neighborhood Watch, Gated Village / Boom Control |
| Security at the property (House) | Security Gates – All opening doors, excluding swivel/pivot doors, Security Gates – All opening doors, Burglar Bars – All opening windows, Burglar Bars – All windows (including non-operable windows), Alarm – Not linked |
| Require accidental & mechanical cover? |
Yes Insured Amt: 85421 |
| Require power surge cover? |
Yes Insured Amt: 67867 |
| Personal All Risk Cover | Both |
| Unspecified All Risk Insured Amount | 25642 |
| Specified All Risk Cover Items |
Item Description: toy Item Amt: 452 Item photo/valuation certificate/proof of purchase |
| Vehicle Details (Motor / Motorcycle / Caravan / Trailer / Ride-On Mower / Golf Car / Shopping Rider / Quad Bike) | |
| Vehicle type | Motor Make: Volvo Model: 2003 Year Manufactured: 2025 |
| Registered Owner | Child |
| Registered Owner | Title: mr Name: ari jack ID no.: 0843478767867 Marital Status: Deceased Occupation: unemployed |
| Drivers License date of issue | 12.02.2025 |
| Drivers License Code | C1 – GVM < = 16, 000kg |
| Vehicle Financed | Yes |
| Vehicle Financed – yes | Company/Bank Name: Company Name Account Number: 1236846 Expiry Date: October 25, 2025 |
| Credit Shortfall | With Residual Residual Percentage: 45% |
| Tracking device | Yes
|
| Overnight Parking | Behind Locked Gates |
| Other | |
| Insured Amt | 352 Insured Amt File |
| Extras on vehicle | Audi, 123543 Extras description: Red, 453 Insured amt: 35, 4 |
| Personal Accident Cover | Yes |
| Cover for: | Spouse |
| Insured Person | Title: Mr Name: Ariana Jack ID no.: 0215435136258 Marital Status: Widowed Occupation: unemployeed |
| Beneficiary | Title: Mrs Name: Ari jsc ID no.: 5215031037084 |
| Insured Amt | 2535 |
| Watercraft Cover | Yes |
| Watercraft type | Inflatable Boat Make: test Model: test Year Manufactured: test If Other: |
| Hull Length | 25mm |
| Insured Amount – Watercraft (Excluding: Engines / Specified Accessories / Trailer) | 45,386m |
| Insured Amount – Specified Accessories | Type: red Insured amt: 25 |
| Insured Amount – Engines | Type: Outboard No. of Engines: 5 |
| Engine | Make: 555 Model: ref Year Manifactured: 2002 Horsepower: 36 Insured amt: 55586 |
| Engines Extras | Glitter Paint |
| Insured amt: |
543453 |
| Is Watercraft Financed | Yes |
| If yes- | Copmany/Bank Name: 390 Account No.: 434688663 Expiry Date: October 21, 2025 |
| Is credit Shortfall Required? | With Residual Residual Percentage: 56% |
| Registered Owner: | Policy holder/Insured |
| Overnight Parking Address: | tes st, test 3, Western Cape, cpt, 7130 |
| Area of Use: | Coastal |
| Storage: | Dock |
| Optional Cover: | Repatriation costs from extended countries |
| permission to the insurers to share policy information and to perform a credit check with various credit bureaus to enable them to do proper underwriting and prepare a quotation. | Yes |
| Signature |  |
| Date of Signing | October 21, 2025 |