KIS Online Questionnaire

KIS Online Questionnaire
Please complete the below questionnaire as accurately and as fully as possible so that we can provide you with the most appropriate quotations for your insurance needs. In order to save you the time, please try and fill in every question, this way we will be able to get you full and accurate quote's straight away!
Select the cover options below that you would like to be quoted on (The relevant questions will then appear below) *

1 Vehicle Quote Buildings & Home Contents Quote Buildings, Home Contents & 1 Vehicle Quote
Personal Details:
Who is your KIS broker? *
If you do not have a KIS broker yet, select Head Office.
Name *

Title First Name Last Name
Marital Status *
ID Number *
Occupation *
Email Address *
example@example.com
Cell Phone Number *

Area Code Phone Number
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Postal Address (If different from above)

All Risk Cover
Unspecified all risk cover amount (R)

Specified all risk (Please enter the description of the item that you would like to insure, the Serial number [if you have it] and the replacement/retail value of the item) - (E.g. iPhone 6s 64GB IMEI: 335406442590 R15000)

	Description	Serial Number	Replacement Value
Item 1
Item 2
Item 3
Item 4
Item 5

Personal Liability Cover
Required Indemnity Limit
Standard is R 2 500 000.00

Vehicle Cover
Vehicle Make & Model
Year Model
Vehicle Colour
e.g. white, blue, silver, black
Transmission
Registered owner of the vehicle

Title First Name Last Name
Use of vehicle
Overnight parking address of the vehicle

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Overnight parking security in place
Daytime parking address of the vehicle

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Daytime parking security in place
Is there a tracking device installed in the vehicle?

Yes No
If yes, which tracking device is installed?
e.g. Tracker Care
Cover Required
Current Retail Price of the vehicle (R)
If you are not sure, leave this blank and we will check on our systems for you.

Vehicle Extra's

	Item Description	Replacement value
Item 1
Item 2
Item 3
Item 4
Item 5

Check the following cover extensions that you would like to include

30 Days car hire 60 Days car hire Basic Excess Waiver Credit Shortfall Tyre Sure
Regular Driver Details:
Regular driver name

Title First Name Last Name
Regular driver ID number
Year that the driver's license was first issued
Driver License code
Do you require quotes for more than 1 vehicle? (We will contact you for the additional vehicle information)

Yes No

Additional Cover

Check the additional items below that you require cover for and we will contact you for the information
Select one or more of the following:

Motorcycle(s) Watercraft(s) Caravan(s) Trailer(s) Other

Insurance History Check

Please complete the following questions as accurately as possible as it will determine the NCB (No claim bonus) points and discounts that we will be able to allocate to you on your quotations. Please give us permission to request your current insurance policy and claims history from your current insurance company so that we can save you time and make sure our quotes are as accurate as possible!
The quoted premium or policy acceptance is subject to the following financial declaration/ information:

Neither I, nor anyone I intend covering under this policy has had any insurance cancelled, been asked to seek alternative insurance, refused renewal of insurance by an insurance company, broker or insurance administrator.‎ I do not have any adverse financial information to disclose relating to me or any business entities I have an interest in or a intend covering under this policy. This includes judgments’, defaults liquidations, sequestrations or administration orders.‎
Current Insurance Company
e.g. Santam, Discovery, Outsurance etc.
Current Policy number
Number of years uninterrupted insurance (Total number of years that you have had insurance, this could be with different insurers as long as there wasn't more than a 3 month gap of not having insurance)
Please give us a description of any claims that you have had in the last 5 years (these include vehicle claims, buildings claims, all risk claims, household content claims, personal liability claims etc.). If it was a vehicle accident, please also state the drivers name who was driving the vehicle at the time of the accident. (e.g. 2015 - vehicle accident - driver: John Doe - R140 000.00)
Please tick the boxes below in order to give us permission to access your policy schedules, claims history in order to give you the most accurate quotations that we can (We promise we won't share your information with anyone other than the insurance companies from which we will be receiving quotes from)

I hereby give Kern Insurance solutions permission to request and receive my current policy schedule as mentioned above‎ I hereby give Kern Insurance solutions permission to request and receive my claims history from the insurer mentioned above‎
If you have your current policy schedule and claims history on hand, please upload it below and send it to us, we will then do comparative quotations for you.

Browse Files

Cancel of

Client Declaration & Signature
FSP details: Kern Insurance Solutions Consult (Pty) Ltd, Registration no. 2005/007574/07 is the holder of a category I Financial Services Provider License with FSP number 25031. The licence includes the authority to provide financial services with respect to Short Term Insurance (personal lines and commercial lines). Kern Insurance Solutions Consult (Pty) Ltd has contracts with various Short Term Insurers in South Africa. Please request us for a list of Short Term Insurers with which we hold contracts if you wish to obtain more information in this regard. The business has not earned more than 30% commission from any of the insurers within the past 12 months, and also does not hold more than 10% shares in any insurer. From time to time we may receive an award from a product provider. Please request us for our gift register if you wish to obtain more information in this regard. Kern Insurance Solutions Consult (Pty) Ltd does hold professional indemnity cover. We have a policy on Conflict of Interest and a copy is available on request. It is hereby declared that Richard Matthews, Salome Grobler, Richard Matthews, Christy Janse van Rensburg, Dirkie Grove and Calvin Simigianis are Representatives working under supervision. We have a complaints resolution system which you will find at our office. If you have any queries or concerns, please don’t hesitate to send us a message via fax at 012 809 3326 or e-mail wynandkern@kis.org.za. Compliance officer: Trevor Laubscher: Moonstone Compliance (Pty) Ltd; 25 Quantum Street, Technopark, Stellenbosch. Tel: (021) 883 8000. Fax: (021) 883 8005 or (021) 883 2590. PO Box 12662, Die Boord, 7613, Stellenbosch.
I hereby declare that all the information that I have provided above has been completed to the best of my ability and as accurately and truthfully as possible and that I agree and acknowledge the terms and conditions mentioned above. *

I acknowledge and accept the terms & conditions and declaration above‎
We at KIS always comply with the set of rules, guidelines and laws as set out by the FSB. The FSB requires that the client signs the questionnaire to declare that the information they have filled in is correct and true. Please sign this questionnaire by using the digital signature below.
Sign Here: *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

KIS Online Questionnaire

Buildings & Home Contents

All Risk Cover

Personal Liability Cover

Vehicle Cover

Additional Cover

Insurance History Check

Client Declaration & Signature