• 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!

  • Personal Details:
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  • Buildings & Home Contents

    Please answer the following information in order for us to provide you with accurate quotations to cover your personal risks.
  • Home Security:
  • IMPORTANT! Please only select security complex/estate above if it meets the following conditions and requirements: Access control fully manned over 24hrs (entry and exit controlled). The access is restricted (i.e. by intercom) and the complex must be entirely enclosed & surrounded by a wall. Electric fencing must exist on the entire perimeter wall surrounding the complex which is linked to a fully monitored control room (with armed response).edit this text...

  • Sum Insureds:
  • All Risk Cover

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  • Personal Liability Cover

  • Vehicle Cover

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  • Regular Driver Details:
  • Additional Cover

    Check the additional items below that you require cover for and we will contact you for the information
  • 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!
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  • 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.

  • 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.

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