Application by:  Agent Landlord Tenant

WHAT IS BEING RENTED
 House Flat Plot Etc




How long have you lived here?
Have you lived here in the last 12 months?

NAME OF LANDLORD

NAME OF TENANT

DEBIT ORDER AUTHORITY
I hereby authorise Innovation Bureau to debit my account with the agreed monthly Insurance premium and collection fee.
I understand that should my payment not be received by Innovation Bureau 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. The onus lies on me, the insured Tenant, to check that my monthly Insurance premium and collection fee have been paid.



Notice: Debits cannot be raised through FNB Savings, Master Card Holders or account numbers exceeding 13 digits
Debit order date
 1st 7th 15th

QUESTIONS FOR ALL TYPES OF PROPERTIES All questions answered “yes must be explained”
1. Are you aware of any visible damage to:
Exterior yes no 
Entrance hall yes no 
Bedrooms/Lounge yes no 
Kitchen yes no 
Shower/Toilet yes no 
If yes, please describe damage:

Have you suffered any losses / claims during the past three years (whether insured or not)?
 yes no
If yes, provide details below:

Declaration

• 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.
• I/We agree that Landlord and Tenant have inspected the dwelling in terms of [S5(3)(E)] of the Rental Housing Act, 1999 and that such list of defects has been attached to a written lease [S5(7)].

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