Tender Reference

Head Office, Cape Town39 Willowweg/ Road, Stikland, 7530

Posbus / PO Box 131, Bellville, 7535

Tel: 021 948 4011

Fax: 021 946 4252

Email: capetown@jhretieflogistics.co.za

Gauteng1008 Kruger Ave, Lyttleton

Posbus / PO Box 10464, Centurion, 0046

Tel: (012) 644-0071

Fax: (012) 644-1330

Email: pretoria@jhretieflogistics.co.za

BELANGRIKU word sterk aangeraai om goedere en meubels/huisinhoud vir

volle vervangingswaarde te verklaar. Geen eis sal betaal of

oorweeg word vir artikels wat nie op die vorm verskyn nie. Eise sal

geskik word in terme van totale verklaarde waardes. Sien

IMPORTANTYou are strongly advised to declare goods and furniture/household

content for its full replacement value. No claims will be paid or

considered for items not mentioned on the form. The claim will be

settled in terms of the total declared values. See Annexure A for

Email: capetown@jhretieflogistics.co.za

Web: www.jhretieflogistics.co.za

Email: pretoria@jhretieflogistics.co.za

Web: www.jhretieflogistics.co.za

AANSOEKER /APPLICANT HUIDIGE WOONADRES / CURRENT RESIDENTIAL ADDRESS

AFLEWERINGSADRES / DELIVERY ADDRESS IF DIRECT DELIVERY GAAN U MEUBELS GESTOOR WORD /

WILL YOUR FURNITURE BE STORED?

oorweeg word vir artikels wat nie op die vorm verskyn nie. Eise sal

geskik word in terme van totale verklaarde waardes. Sien

aanhangsel A vir polisterme.

considered for items not mentioned on the form. The claim will be

settled in terms of the total declared values. See Annexure A for

policy terms.

DATUM VAN VERHUISING / REMOVAL DATE TIPE VERVOER / METHOD OF TRANSIT

Seevrag / Sea Freight Lugvrag / Air Freight Pad vervoer / Road transport

VUL ASSEBLIEF DIE INVENTARIS MET DIE WAARDE VAN ITEMS IN / KINDLY COMPLETE THE INVENTORY WITH THE VALUE OF ITEMS

Tipe/Make Model

Noitems

Vervangingswaarde/Replacement cost

A. Elektriese Toebehore/ Electrical Appliances

Tipe/Make Model

Noitems

Vervangingswaarde/Replacement cost

Yskas/Refrigerator Telefoon-Faks/Telephone fax

A. Elektriese Toebehore/ Electrical AppliancesYskas/Refrigerator Telefoon-Faks/Telephone faxVrieskas/Deepfreeze Televisie/TelevisionMikrogolf/Microwave Draagbare TV/Portable TVMini-oond/Mini oven Video-opnemer/Video recorderVoedsel verwarmer/Hot tray M-Net dekodeerder/decoderTweeplaatstoof/Hot plate Satellietskottel/Satellite dishStoof/Stove TV Antenna/TV AerialWasmasjien/Washing machine Stereo toerusting/equipmentTuimeldroer/Tumble dryer Klank versterker/AmplifierTuimeldroer/Tumble dryer Klank versterker/AmplifierSkottelgoedwasser/Dish washer Luidsprekers/SpeakersKetel/Kettle Kompakspeler/CD PlayerStrykyster/Iron Kassetspeler/Tape deckRooster/Toaster Draaitafel/Turn table"Snackwich" Draagbare radio/Portable radioKoffiemaker/Coffee maker Draagbare bandopnemer/recorderVoedsel verwerker/Food processor Projektor,skyfies/Projector, slidesElektriese mes/Electrical knife Klokradio/Clock radioVersapper/Blender Skeermes/RazorVersapper/Blender Skeermes/RazorWafelmaker/Waffle maker Sakrekenaar/CalculatorStadige kookpot/Slow cooker Haardroer/Hair dryerHandklitser/Hand mixer Haarkrullers/Hair curlersRooster oondjie/Toaster oven Breimasjien/Knitting machineBlikoopsnyer/Tin opener Naaimasjien/Sewing machineElektriese braaipan/Frying pan Omkapmasjien/OverlockerOlie braaier/Oil fryer Tikmasjien/Type writerElektriese/Electrical fondue Rekenaar/ComputerBedieningstrollie/Hot tray trolley Drukker/PrinterBedieningstrollie/Hot tray trolley Drukker/PrinterVerwarmer/Heater Skandeerder/ScannerWaaier/Fan Sagteware/SoftwareLugreelaar/Air conditioner Speletjies/GamesStofsuier/Vacuum cleaner Ander hardeware/Other hardwarePoleerder/Polisher (Specify)Matwasser/Carpet cleanerElekriese kombers/blanketElektroniese orrel/keyboard Ander/Other (specify)Elektroniese orrel/keyboard Ander/Other (specify)Elektroniese klavier/pianoAnder/Other (specify)

TOTAAL/TOTAL (A.) R TOTAAL/TOTAL (B.) R

C. KLERASIE / CLOTHING

Noitems

Vervangingswaarde /Replacement cost

E. BREEKWARE FRAGILES

Noitems

Vervangingswaarde /Replacement cost

G. EETKAMER / DINING ROOM

Noitems

Vervangingswaarde /Replacement cost

MANS/MEN Eetservies/Dinner service (1) Eetkamertafel/tableBaadjies/Coats Eetservies/Dinner service (2) Stoele/ChairsPakke/Suits Teestel/Tea set (1) Buffet/SideboardLeer/Leather/Suede clothing Teestel/Tea set (2) Teetrollie/Tea trolleyBroeke/Slacks Ander breekware - eetkamer/ Kabinet/CabinetKort broeke/Shorts Other crockery - dining room Silwerware/SilverwareTruie/Jerseys Ander breekware - kombuis/ Messeware/CutleryHemde/Shirts Other crockery - kitchen Gordyne/CurtainsNagklere/Sleepwear Glasware/Glassware Skilderye/PaintingsDasse/Ties Kristalware/Crystalware Drank/Wine/SpiritsOnderklere/Underwear Porselein/Porcelain Lamp/LampSkoene/Shoes Marmerblaaie/Marble topsStewels/Boots Ander marmer/Other marble Ander/Other (specify)Kouse/Hosiery Ornamente/OrnamentsSportdrag/Sportswear Spieels/MirrorsStrandklere/Beachwear Ander/Other (specify)Serpe/Scarves TOTAAL/TOTAL (G.) RSakdoeke/Handkerchiefs

Hoede/HatsH. KOMBUIS/KITCHEN

VROUE/WOMEN TOTAAL/TOTAL (E.) RBaadjies/Coats Tafel/Table

Pakkies/SuitsF. SITKAMER/LOUNGE Stoele/Chairs

Rokke/Dresses Kabinette/ChairsLeer/Suede/Leather garments Stoele/Chairs Strykplank/Ironing boardLang broeke/Pants Rusbanke/Sofas Groenterak/Vegetable rackKort broeke/Shorts Sitkamerstel/Lounge suite Potte en panne/Pots and pansRompe/Skirts Koffietafel/Coffee table Messegoed/CutleryTruie/Jerseys Sytafeltjies/Side tables Toebehore/UtensilsBloese/Blouses Vertoonkas/Showcase Plastiekware/PlasticwareNagklere/Sleepwear Tydskrifrak/Magazine rack Vullisblik/Dirt binOnderklere/Lingerie Kis/Kist Kookboeke/Cookery booksSkoene/Shoes Wynrak/Wine rack Nie-bederfbare voedsel/Stewels/Boots Boekrak/Bookcase Non-perishable foodKouse/Hosiery Kabinet/Cabinet Skoonmaakmiddels/Sportdrag/Sportswear Muureenheid/Wall unit Cleaning materialsStrandklere/Beachwear Lessenaar/DeskSerpe/Scarves Laaikas/Chest of drawersHoede/Hats Matte/Carpets Ander/Other (specify)Handsakke/Handbags Tapyte/Rugs

Horlosies/ClocksKINDERS/CHILDREN Lampe/LampsKlerasie/Clothing Boeke/Books TOTAAL/TOTAL (H.) RSkoene/Shoes Klavier/Piano

Musiekinstrumente/instrumentI. BADKAMERS/ BATHROOMS

Ander/Other (specify) Plate/RecordsKompakskywer/CD'sVideo/Audio cassettes Kabinet/CabinetSkilderye/Paintings Gordyne/Curtains

TOTAAL/TOTAL (C.) R Gordyne/Curtains Weegskaal/ScaleMuurbehangels/Wall hangings Toiletware/Toiletries

D. LINNE/ LINEN Kussings/Cushions Tafel/Table

Tafel/Table Medisyne/MedicinesOrnamente/Ornaments Grimeermiddels/Cosmetics

Tafellinne/Table linen Pottebakkersware/Pottery Wasgoedmandjie/Lakens/Sheets Clothing basketKussingslope/Pillowcases Ander/Other (specify) Tapyte/RugsDuvet Oortreksels/CoversDuvets/Quilts Ander/Other (specify)Komberse/BlanketsKussing/PillowsNagval/Night frillsHandoeke/Towels

Ander/Other (specify)TOTAAL/TOTAL (D.) R TOTAAL/TOTAL (F.) R TOTAAL/TOTAL (I.) R

J. SLAAPKAMERS / BEDROOMS

Noitems

Vervangingswaarde /Replacement cost

M.BUITE/OUTSIDE

Noitems

Vervangingswaarde /Replacement cost

Noitems

Vervangingswaarde /Replacement cost

Dubblelbeddens/Double beds Tuintafel/Garden tableDubble kopstukke/Headboards Tuin stoele/Garden chairs Heg aparte lys aan indien nodigEnkelbeddens/Single beds Tuingereedskap/Garden tools Attach separate list if necessaryEnkel kopstukke/Headboards Tuinbank/Garden benchBedkassies/Pedestals Strandstoele/Beach chairsSpieeltafels/Dressing tables Sambrele/UmbrellasStoeltjie/Stool Ornamente/OrnamentsStoele/Chairs Oefen toerusting/Kot/Cot Exercise equipmentKompaktum/Compactum Sport toerusting/Laaikassies/Chest of drawers Sport equipmentBoekrakke/Book cases Kamptoerusting/Kaste/Wardrobes Camping equipmentMatte/Carpets Braai toerusting/equipmentLampe/LampsLessenaars/Desks Ander/Other (specify)Kiste/Kists TOTAAL/TOTAL (O.) RSpieels/Mirrors

Skilderye/PaintingsGordyne/CurtainsBoeke/Books TOTAAL/TOTAL (M.) R OPSOMMING/SUMMARY

Speelgoed/Toys A. ELECTRICAL R

Ornamente/OrnamentsN. MOTORHUIS & STOOR/ GARAGE & STORE B. ELEKTRIESE R

Skoonheidsmiddels/ C. CLOTHING RCosmetics Stoele/Chairs D. LINEN RToiletware/Toiletries Rusbanke/Sofas E. FRAGILES RTasse/Suitcases Swembad toerusting/ F. LOUNGE RHorlosies/Clocks Pool equipment G. DINING ROOM RAnder/Other (specify) Werksbank/Workbench H. KITCHEN R

Kaste/Cupboards I. BATHROOMS RGereedskap kiste/Tool boxes J. BEDROOMS RGereedskap/Tools/(List specialised seperately)

K. STUDYL. MISCELLANEOUS

RR

Rakke/Shelves M. OUTSIDE RGrassnyer/Lawnmower N. GARAGE & STORE R

TOTAAL/TOTAL (J.) R Randsnyer/Weedeater O. VALUABLE ITEMS RLeer/Ladder (s)

K. STUDEERKAMER/ STUDY Kruiwa/Wheelbarrow Ander/Other (lys/list)

Fietse/BicyclesTapyte/Rugs Tapyte/RugsHorlosies/Clocks Swaai/SwingLampe/Lamps Hout/TimberBoeke/Books Boeke/Books SUBTOTAAL/SUB TOTAL RLessenaar/Desk Gasbottels/Gas bottlesStoele/Chairs Branderski's/Paddleski'sLiasseerkabinette/Filing cabinets Seilplank/SailboardRekenaarstaander/Comp.Stand Branderplank/SurfboardSkilderye/Paintings Boot/Boat

Sleepwa/TrailerTOTAAL/TOTAL (K.) R Gordyne/Curtains

Boor/DrillL. ALLERLEI/ MISCELLANEOUS Pottebakkersware/PotteryFotografie toerusting/ Ander/Other (specify)Photographic equipment(Limited to R5000 in total)(R1000 per item maximum)Specify :Silverware/SilverwareKristal/CristalSnoekertafel/Snooker tablePool tafel/table GROOT/GRAND TOTALTreinstel/Train set om te verseker/to be

TOTAAL/TOTAL (L.) R TOTAAL/TOTAL (N.) R insured R

Ek/Ons verlang dat, JH Retief, Volle Aanspreeklikheid aanvaar vir my/ons besending, onderhewig aan hulle Alle Risiko Goedere In Transito Polis voorwaardes en verklaar dat alle inligting korrek

en volledig is en dat ek geen wesenlike feite weerhou het nie. Ek stem saam dat die vorm as grondslag gebruik kan word vir die voorgestelde kontrak tussen myself/ons en JH Retief, die versekerde.

I/We wish apply that, JH Retief, accept Full Liability for my/our consignment, subjected to there All Risk Goods In Transit Policy conditions and declare thereafter that my information is correct and complete and that nothing

materially affecting the risk has been concealed by me. I agree that this form shall be taken as the basis of the proposed contract between me/us and JH Retief, the insured.

DATUM/DATE HANDTEKENING/SIGNATURE

O . WAARDEVOLLE ITEMS VALUBLE ITEMS (bo R1 000 elk/above R1 000 each eg antiques, artworkes, etc..

Our Financial Service Provider (The Broker)Phoenix Risk Solutions (Pty) Ltd FSP License nr: 10150 Postal Address : P.O.Box 140, Newlands, 7725 Tel: 021 683 8383 Fax: 086 511 6286