Reference Number: wmslb
| Consent to POPIA | |
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| 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. |
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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This consent will remain effective until such consent is withdrawn.
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Signed at_______________________________________________________________________________________ this ___________ day of _____________ 20_______________. Name + Surname of Responsible Party (Employee of ProVérte): _______________________________________________________________________________________ Signature: _____________________________________ |
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| 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: | [155] |
| 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: | [283], [284], [285],[286], [287] |
| Contents & Buildings or Both: | Contents, Building |
| Contents Insured amt | Contents: Buildings: |
| 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 | [229] |
| Bond holder details | Bank name: [115] Account Name: [116] Expiry Date: [117] |
| Accidental damage to fixed machinery cover? [275] |
Accidental damage to fixed machinery Insured Amount: [276] |
| Power surge cover? [277] |
Power Surge Insured Amount: [278] |
| Geyser Maintenance [279] |
Maintenance Amount: [281] |
| Building Address | building address. [220], Cape Town, Western Cape, 7130 |
| Premise Use | Main Residence |
| Dwelling type | |
| 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: | < Business details: broken, broken, gone, gone, broken, broken, broken |
| Roof & Wall Construction | < |
| Roof | |
| Walls | |
| Will the dwelling be unoccupied for more than 60 days per year | |
| Will the dwelling be left unoccupied for more than 7 days within the 1st 30-days of cover? | |
| Contents – Security Measures | |
| Security Perimeter | |
| Security Area | |
| Security at the property (House) | |
| 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: [324] Account Number: [325] Expiry Date: [326] |
| Credit Shortfall | With Residual Residual Percentage: 45% |
| Tracking device | Yes
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| Overnight Parking | Behind Locked Gates |
| Other | |
| Insured Amt | 352 Insured Amt File |
| Extras on vehicle | [346] Extras description: Insured amt: |
| Personal Accident Cover | Yes |
| Cover for: | |
| Insured Person | Title: Name: ID no.: Marital Status: Occupation: |
| Beneficiary | Title: Name: [357] ID no.: [358] |
| Insured Amt | [129] |
| Watercraft Cover | Yes |
| Watercraft type | Make: Model: Year Manufactured: If Other: |
| Hull Length | [373]m |
| Insured Amount – Watercraft (Excluding: Engines / Specified Accessories / Trailer) | [374]m |
| Insured Amount – Specified Accessories | Type: [370] Insured amt: [460] |
| Insured Amount – Engines | Type: Outboard No. of Engines: 5 |
| Engine | Make: 555 Model: ref Year Manifactured: 2002 Horsepower: 36 Insured amt: 55586 |
| Engines Extras | |
| Insured amt: | |
| Is Watercraft Financed | |
| Registered Owner: | [396] |
| Registered Owner: | Title: [397] Owner name: [399] ID no.: [400] |
| Overnight Parking Address: | , [404], , , |
| Area of Use: | |
| Storage: | |
| Optional 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 | October 21, 2025 |