PROPOSAL FORM FOR PUBLIC/PRODUCTS LIABILITY INSURANCE FOR SECURITY COMPANIES (NOT CASH IN TRANSIT)

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1 Tel: (011) / Cell: / Fax: Loch Avenue, Parktown, Johannesburg, 2193 P.O. Box 31729, Braamfontein, 2017 PROPOSAL FORM FOR PUBLIC/PRODUCTS LIABILITY INSURANCE FOR SECURITY COMPANIES (NOT CASH IN TRANSIT) Broker: Khanyisa Insurance Brokers Contact person:... Tel:... Fax: IMPORTANT NOTICE It is important that you provide full and detailed answers to all questions to enable the underwriter to properly assess the risk and quote terms that are fair and reasonable to both parties. Incorrect or non-disclosure by you of material information may impact on any claims arising under your policy. Do not sign any blank or partially completed proposal form; complete all forms in ink. Keep all documents handed to you and make note of what is said to you. Don t be pressurised to buy the policy. 1. General information 1.1 Name of company:. 1.2 Vat Registration No: 1.3 Registered address: 1.4 Postal address: 1.5 Website / address:. 1.6 Business Description:. 1.7 Date company established:. 1.8 Annual turnover: R Annual Wages: Company Registration Number: 2006/035498/07 VAT Registration Number: An Authorised Financial Services Provider: License Number % BEE Rating

2 1.9 If the company operates outside South Africa please give details of the territories and percentage of business operations applicable: If the company has changed its name and/or country of registration in the last 5 years please give details: 2. Details of ownership 2.1 Indicate legal status of company (public co, private co, Section 21 co, etc):. 3. Details of subsidiaries 3.1 Please give details of any subsidiaries to be included in this insurance: NAME BUSINESS % OWNERSHIP 4 Work-force details 4.1 Total Number of employees (permanent and part time) 4.2 Please give a split in the workforce by occupation Occupation Unarmed Guards Armed Personnel Administrative and monitoring staff Personnel with dogs Personnel with vehicles Number 4.3 Please provide a breakdown of staff by grading in terms of the provisions of the Wage Determination Act 460 of 1957 (as amended) Grade A Grade B Grade C Grade D Grade E 4.4 Do you confirm registration of all employees with the Security Officers Board? Yes/No If No, please provide details. 4.5 Do you screen employees for criminal records prior to employment? Yes/No If yes, is this done in house or through an agency? 2

3 4.6 In terms of the policy, all security personnel must be trained through an accredited institution. Please provide details of training courses undertaken Course Name Institution Compulsory Yes/No 4.7 Do you conduct random polygraph testing on employees? Yes/No. 5 Business Activity 5.1 Please provide a breakdown (by turnover) in the types of services provided Activity Turnover % of total Guarding Access Control Cash in Transit Body guarding/vip Protection Shoplifting surveillance Polygraph testing Employee surveillance Consulting Insurance Investigations Tactical/Armed Response RESIDENTIAL Tactical/Armed Response COMMERCIAL Alarm Installation and repair CCTV Installation and repair Repossessions and Collections 5.2 Please provide a % split in the types of industries serviced by your organisation Business Armed Unarmed Mining Banking Retail Casino or gaming Hotels and hospitality Industrial Logistics and warehousing Construction Sites Schools Airports Events/Stadiums 5.3 Do you provide any emergency medical or paramedic services to clients? Yes/No 3

4 5.4 If you supply alarms or CCTV equipment please provide the turnover. 5.5 Please attach a copy of your standard trading conditions Do you have workers operating outside of the Republic of South Africa? Yes/No. 6. Insurance history 6.1 Does the company currently have Public Liability or Professional Indemnity insurance? If yes give details:. 6.2 Has an insurer ever cancelled, refused to accept or renew any Public/Products Liability insurance or imposed special conditions for the company or its predecessors in business? If yes give details: During the last five years has the company or its predecessors in business made any claim under a Public, Products or Professional Indemnity Liability policy?. If yes please give details: During the past 5 years has the company or its predecessors in business had any legal action instituted against them following the loss of or damage to third party property? If yes please give details:.. 7. Cover required Cover Limit Deductible Public Liability Products Liability Errors and Omissions (PI) Retroactive Date 4

5 8. Additional information Please attach copies of any brochures detailing services offered Please attach a copy of your standard trading conditions. Please attach a copy of your highest turnover contract DECLARATION We declare that the statements and particulars in this proposal are true and that we have not misstated or suppressed any material facts. We agree that this proposal together with any other information supplied by us, shall form the basis of any contract of insurance effected thereon, and shall be incorporated therein. We also declare that no other policy is in force, or will be effected during the currency of the policy now proposed other than the policy declared under 4.1. of this proposal. We undertake to inform the company of any material alteration to these facts, whether occurring before or after completion of the contract of insurance. Signing this proposal form does not bind the proposer to complete this insurance, nor does it bind the company to accept the proposal. SIGNATURE OF PROPOSER... DATE... 5

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