Order Form – Qantam Risk Assessment

Order Form - Private Domestic Clients | Commercial Property

Please note that we will send you a Pro Forma invoice prior to the appointment being made. Our surveyors are instructed to collect payment at the time of the survey. Please pay by cheque, debit order or EFT by producing confirmation of payment by emailing orders@qantam.co.za. The completed survey will be sent once captured (usually within 15 working days) and after receipt of payment. We trust that you understand that due to previous experience, we are unable to produce the survey until we have received payment - thank you. Kindly ensure that your billing details are correct when filling in this order form.

Name*

Insert your first name

Last Name*

Insert your Last Name

Telephone No.*

Insert Telephone number

Email*

Enter Email Confirm Email

Insert your email address

Fax

Insert your fax number if applicable

What type of Evaluation do you require?*

Residential
Commercial

Please arrange a valuation for the following client

Select One or more*

If selecting more than one, please hold the control (ctrl) when making your selection.

Client Details

Client Name*

Insert your clients first name

Client Surname*

Insert your clients Surname

Client's Policy Number*

Please insert the clients policy number

Client's Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Contact Details

Work Telephone No.*

Insert Clients Work Telephone number

Home Telephone No.*

Insert Client's Home Telephone number

Email*

Enter Email Confirm Email

Insert your client's email address

Cellphone No.*

Insert Clients Cellphone number

Insurance Details

Underwriter*

Broker*

Current Householders

Contents Sum Insured*

A/R Specified Insured Amount*

A/R Unspecified Insured Amount*

Total*

Are you aware of the presence of Valuable Artwork, Antiques & Carpets?

Yes
No

Current Houseowners*

Insert Current Houseowners value in Rands

Reason for Survey Request

Party Responsible for Payment / Billing details

Full Name*

Insert your full name

Telephone No.

Insert Telephone number

Cellphone No.

Insert Cellphone number

Email*

Enter Email Confirm Email

Insert email address

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

VAT No.

Insert your VAT No. if applicable

If the property is rented/let to a tenant

Name of Tenant*

Insert tenant's full name

Tenant Email*

Enter Email Confirm Email

Insert tenant email address

Tenant Tel.

Insert Tenant Tel. number

Purpose of Occupancy

Lease ending

Occupied as

Reason for evaluation

New
Reassessment
Claim

Type of occupancy

Complex/Townhouse
Industrial/Factory
Office/Retail
B&B/Guest House
Lodge/Game Farm

Complex/Townhouse

No. of Units

PQ Ratio

Communal Area

Yes or No

Other Info

Industrial/Factory

No. of Buildings

Industry Type

Other Info

Office/Retail

No. of Workstations

No. of Private Offices

No. of Boardrooms

No. of Kitchens

List other Rooms & numbers

Other Info

B&B/Guest House

No. of Bedrooms

No. of Self Catering

Other Info

Lodge/Game Farm

No. of Chalets

Other Info

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