(* = compulsory)

Property Information

Purpose of Valuation* --Please Select-- replacement cost insurance market price

Zoning* --Please Select-- residential commercial industrial farm

Ownership Type* --Please Select-- freehold sectional title share block vacant land

Current Market Value (estimated)* --Please Select-- less than R 1.000.000 R 1 million - R 2 million R 2 million - R 3 million R 3 million - R 5 million R 5 million - R 10 million more than R 10 million

Number of Sectional Title / Share Block Units* --Please Select-- 2 units 3 units 4 units 5 units 6 units 7 units 8 units 9 units 10 units 11 units 12 units 13 units 14 units 15 units 16 units 17 units 18 units 19 units 20 units 21 units 22 units 23 units 24 units 25 units 26 units 27 units 28 units 29 units 30 units 31 units 32 units 33 units 34 units 35 units more than 35 units

Erf No.

Street Name*

Street No.*

Name of Complex*

Name of Building*

Name / No. of Farm*

Section / Unit No.*

Suburb / District*

City / Town*

Province* --Please Select-- Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga North West Northern Cape Western Cape

Contact person for Access to Property*

Tel. / Cell No. for Access to Property*

Special Instructions

Valuation Requested By

same as contact person above

Your Full Name*

Company Name to be invoiced

Street Name (for Invoice)

Street No. (for Invoice)

P.O. Box (for Invoice)

City / Town (for Invoice)

Postal Code (for Invoice)

Your E-mail Address*

Your Tel. No.*

VAT No.

Amount payable (incl. 14% VAT)R

For Brokers only

Broker Name

Broker No.

Insurance Policy No.

Name of Insured

Current sum insuredR

Attach Participation Quota Schedule

* I have read and agree to Mirfin`s Terms & Conditions.