On-Line Application Form

Please fill out the form below to apply for NetAsset insurance

A. Client Details

Company Name:

Registration No:

Title*:

*denotes required fields

First Names*:

Surname*:

Identification No*:

Postal Address*:

Postal Code*:

Physical Address*:

Postal Code:

E-mail*:

Cell*:

Telephone*:

Fax:

B. Asset Tracking Plus Insurance Cover - Monthly Contract

Make and Model*

Exact Serial Number*

          Value*
1:

1:

 R
2:

2:

 R
3:

3:

 R
4:

4:

 R
5:

5:

 R

NetTrace Installation is Compulsory

Included at no cost if done at approved agent's premises, or if installed electronically via e-mail.

For customer site installations, a minimum call-out fee of R300 applies; R60 per additional laptop. Please note that this is currently only available for computers running Microsoft Windows or Apple Macintosh operating systems. 

NetTrace Tracking Fee =

 R 35-00 per Laptop

In the event of a claim 

Insurance excess 10% of claim - Min R1,000

 - Software reinstallation not included

 

Total Monthly Deduction =

 R

C. Declaration / Debit Order - I / We declare that the above particulars are true in every respect
-------------------Insured / Account Holder's Signature---------------------  
Capacity*:
Date*:

I/We request NetAsset/NetTrace or their authorised agent to draw against my/our account due amounts payable in terms of this contract. I further request the bank/institution to pay and debit my/our account with all such amounts drawn. If the account holder is a company, its exact name must be entered and the authorised officer/s must affix the company stamp/seal, sign and state his/her title within the company. The applicant acknowledges and agrees that upon the applicant's signing hereof, the applicant has read, understood and agreed to NetTrace's Terms and Conditions and Suretyship, available from www.netasset.co.za.

Account Type*:

Account Name*:

Account Number*:

Bank*:

----------------------- Signature of Account Holder-------------------------

 Branch*:
Branch Code*:
Date*:

Please sign and return application form to Fax 011 267 6296