Agent Sure

  • Premium: R40.00
    Binding fee: R20.00
    Total Premium: R60.00 per month
    Limit of Indemnity: R5million
  • Insured Person
  • The income disclosed needs to be for a 12 month period and should be in line with your financial year. Accurate income figures are required.
  • - Any claim/s being made or settled?
    - Any circumstance/s that could lead to a claim being reported to Insurers?
  • I hereby authorise LSG Insurance Services or its authorised administrator to debit my account with the agreed monthly Insurance premium and collection fee. I understand that should my payment not be received by LSG Insurance Services or its authorised administrator by the 15th, there is no Insurance cover from the 1st day of that month and the Insurance policy will be cancelled, unless prior arrangements have been made.
  • Notice: Debits cannot be raised through FNB Savings, Master Card Holders or account numbers exceeding 13 digits
    • I/we declare that after proper enquiry the statements and particulars given above are true and that I/we have not miss-stated or suppressed any material fact.
    • I/we agree that this Proposal Form, together with any other material information supplied by me/us shall form the basis of any contract of insurance affected thereon.
    • I/we undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract.
    • I/We understand that submitting this electronic declaration form will from the basis of this contract.
    Copy of policy wording available on request.