Title *
First name *
Surname *
Identity account number (if applicable)
Identity number *
Inception date *
Postal address *
City *
Postal code *
Physical address
Postal code
Fill in at least one contact number **
Home telepone number **
Work telepone number **
Cellphone number **

* Have you lodged a cellphone claim with Hollard Insurance in the last 24 months?

Inception of insurance will be from commencement date to month end and any subsequent month period for which the Insured shall pay and Hollard shall accept a renewal premium. This is to certify that cover has been arranged on all ALL RISKS basis with Hollard subject to the terms of the Policy on the following insured item.

Make *
Model *
IMEI number *
Sim card number *
Cellphone number *

Premium per month please select one:

Up to R1,000 R36
R1,001 - R1,500 R39
R1,501 - R2,000 R45
R2,001 - R3,000 R55
R3,001 - R4,000 R65
R4,001 - R5,000 R74

In response of each and every event that gives rise to a claim within the first four (4) months from inception of the policy, the Insured will be responsible for 40% (forty percent) of the sum insured. In respect of each and every event that gives rise to a claim after the first four (4) months from inception of the policy, the Insured will be responsible for 10% (ten percent) of the sum insured, minimum of R150 (one hundred and fifty rand) excess.


As per your instruction all monies due will be debited from the following account on or around the 1st (first) day of each calendar month. Please remember that if the debit order is not met, then the no premium, no cover conditions of this policy will apply.

Bank/Building Society *
Branch *
Account number *
Branch code *
Name of account holder *
Type of Account *

NB: This cellular telephone policy has been specially arranged for Identity Limited (Identity) by The Hollard Insurance Company Limited (Hollard) to be sold to customers through their various retail stores. The policy wording, as amended from time to time, drawing information from various administrative forms, application forms, certificates, declarations and authorisations, form the basis of your insurance contract between You (The Insured) and Hollard. Identity Limited is an authorised Financial Services Provider. FSP No: 15089.

Hollard | Underwritten By Hollard

* I hereby authorise Hollard to deduct the premium amount as stipulated from the above mentioned institutions in any way that Hollard and the Institution have agreed upon. All such withdrawals from my bank account will be treated as if I had signed them personally. Details of withdrawals will be stated on my bank statements. I hereby acknowledge that all the information regarding the insurance cover has been disclosed to me including the statutory notice. I hereby declare that I have read and completed, whether in my/our handwriting or not, the above mentioned application, that the information is true and correct, and I acknowledge and understand the contents thereof. I furthermore confirm that I have signed the declaration of my own free will and I regard it as binding.

* I agree to these terms and conditions