Professional Indemnity

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Godfrey Carter
8 years ago
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1 POPOSAL FOM Professional Indemnity 1. This Proposal Form has been compiled in such a manner as to provide Underwriters with as much detail as possible with regard to evaluation of the insurance requirements. Completion of this form does not bind the Proposer or Underwriters to complete the insurance transaction. 2. To assist Underwriters in accurately assessing liability for rating purposes, Proposers are requested to answer all questions with either: elevant details,, No or Nil answers. Where /No answers required, please mark the appropriate box with an X. 3. Please answer All questions fully, replies such as see your records, or as previously advised are not acceptable. 4. If the space provided is insufficient, a separate sheet should be attached. DISCLOSUE You must disclose to the Insurer/Underwriter all information which is material to it in deciding whether to issue insurance cover to you, including any facts or conduct which might lead to a claim being made against you. Failing to do so could affect your rights to indemnity. If you do not understand any part of this document, please contact your Broker BEFOE YOU SIGN IT. You will be bound by the answers, which are given, and by the information provided by you in this Proposal Form. It is in your interest to make sure that all information is correct and properly understood. When in doubt disclose ATTACHMENTS Before you return this form, have you included the following (please indicate by ticking the boxes): Standard client contract agreement: Company brochure/ additional information: Claims information (if relevant): Tradeforth 6 (Pty) Limited trading as Abelard Underwriting Agency F.A.I.S. Compliance Details egistration No 1996/008912/07 FSP Licence Number: 28 Manor House, 6 Conrad Drive, Blairgowrie, 2193 Compliance Practice: Intelligent Compliance and Education (Pty) Ltd PO Box 2155 Pinegowrie, 2123 FSB Practice No: 554 Tel , Fax (Local) (Intl) Compliance Officer: Peter Veal Directors: DJC Cox (Managing), CE Diederiks, CP Norrington* *British, K L Waugh D s f 1 PI Miscellaneous (2011)

Completion of this form does not bind the Proposer or Underwriters to complete the insurance transaction. 2.

2 Page 1 of 8 Part 1 General Information 1. Details of Assured 1.1 Title of Assured / Practice: 1.2 Telephone Number: 1.3 Fax Number: 1.4 address: 1.5 VAT egistration Number: 1.6 Company egistration Number: 1.7 Website address: 1.8 Present Legal Constitution (Mark relevant box below): Sole Practitioner Partnership Incorporated Co. Limited Co. Closed Corp. 2. Adresses of Practice: 2.1 Principle Office: Partner/Principal in Charge: 2.2 Subsidiary Office: Partner/Principal in Charge: 3. Date of commencement of Practice 3.1 As currently constituted: 3.2 As initially established: 4. Discipline(s) in which engaged

8 Present Legal Constitution (Mark relevant box below): Sole Practitioner Partnership Incorporated Co. Limited Co. Closed Corp. 2. Adresses of Practice: 2.

3 Page 2 of 8 5. Names and Qualifications of Principals i) In case of Partnerships Partners ii) In case of Incorporated Companies Directors iii) In case of Limited Companies Professionally qualified Directors and Employees iv) In case of Closed Corporations Members Name Qualifications Date Qualified How long Principal in this Practice 6. Have any claims ever been made against the Proposed Assured / Partners / Directors / Members or Employees for the type of cover for which you are now applying? No If, please provide full details: 7. Are any of the Proposed Assured / Partners / Directors / Members or Employees, AFTE ENQUIY, aware of any circumstances which would be covered under a policy of this type that may result in any claims or any possible claims being made against them? No If, please provide full details (attach a page to the back if necessary):

Employees iv) In case of Closed Corporations Members Name Qualifications Date Qualified How long Principal in this Practice 6.

4 Page 3 of 8 8. Are you at present of have you in the past been insured? No If, please provide the following details: a) Name of insurers: b) Indemnity Limit: c) Excess: each and every claim d) Date of expiry of cover: e) Whether policy includes un-off cover? No and if so, for what period? 9. Is indemnity to apply to any Principal who has left / retired / died? No If, please state: Name Qualifications Date Qualified How long Principal in this Practice 10. For the type of insurance now being proposed, has any insurer ever : i) declined a proposal or renewal for this Practice or any Partner / Principal? No ii) required an increased premium or imposed special terms? No iii) cancelled an insurance? No If any answer is YES, please give full details: 11. Do you require cover in respect of any liability incurred but not discovered prior to the effecting of this insurance at a single premium to be negotiated? No

No and if so, for what period? 9. Is indemnity to apply to any Principal who has left / retired / died? No If, please state: Name Qualifications Date Qualified How long Principal in this Practice 10.

5 Page 4 of Declaration: I/We hereby declare that the above statements and particulars contained in Parts 1 & 2 of this Proposal are true and complete, that at the present time, other than as stated, I/we have no reason to anticipate any claim under the insurance now being requested. I/We agree that this Proposal and declaration shall be the basis of the contract between me/us and the insurers/underwriters. Date Signature of Proposer

Proposal are true and complete, that at the present time, other than as stated, I/we have no reason to

6 Page 5 of 8 POPOSAL FOM Miscellaneous E & O Professions Part 2 Additional Information 1. Describe in detail the nature of your business? 2. Staff complement Total number of: a) Partners / principals / Directors: b) All other staff: Names of all Qualifications Year How If less than 5 years Directors / Partners obtained long a practical experience in Director / this occupation, please Partner give details of previous in firm occupations c) If Sole Director / Partner, is this a part time occupation? No If, please give brief details of present full time occupation.

Staff complement Total number of: a) Partners / principals / Directors: b) All other staff: Names of all Qualifications Year How If less than

7 Page 6 of 8 3. Does the firm perform work outside SA or work for clients outside SA? No If, please give details, including proportion of fees from this work. 4. Are any major changes in the firm s activities planned or expected within the next two years? No If, please give details. 5. Does the firm use a standard form of contract, agreement or Letter of appointment? No If, please enclose copies. 6. Does the firm issue any Brochure, Leaflets, Books etc describing the Firm s services or offering any service or facility? No If, please enclose copies. 7. Is any work put out to sub-contractors? No a) Does the firm require the sub-contractors to carry Professional Indemnity insurance and for what Limits of Indemnity? No b) What percentage of the firms fees is paid to sub-contractors? 8. Is the firm or any of the Directors/ Partners connected or associated (financially or otherwise) with any other firm, company organisation? No If, please give details, including proportion of fees from this work.

Does the firm use a standard form of contract, agreement or Letter of appointment? No If, please enclose copies. 6.

8 Page 7 of 8 9. Quotations equired Limit any one period of insurance inclusive of costs and expenses Deductible (Excess) (The amount carried by Assured per claim) 10. Do you require one or two reinstatements of the indemnity during the period of insurance? No Number of reinstatements? One Two 11. Fee income (VAT exclusive) (This question must be completed accurately as the figures are used for rating purposes) a) Please give gross fees received during the past five years: Year End Fees 1) 2) 3) 4) 5) b) Please give the estimated fees for the coming twelve months: c) Financial Year End: 12. Do you require any of the following Extensions? 12.1 Dishonesty of staff other than Principals/Directors. No 12.2 Additional Assured (names or persons not employed directly by the Assured who are remunerated on a commission only basis and who are to be indemnified in respect of their activities as members of the Assured s staff). No If, please name them together with their experience and qualifications: Name Qualifications Years experience in insurance industry

Fee income (VAT exclusive) (This question must be completed accurately as the figures are used for rating purposes) a) Please give gross fees received during the past five years: Year End Fees 1) 2)

Accountants Professional Indemnity

POPOSAL FOM Accountants Professional Indemnity 1. This Proposal Form has been compiled in such a manner as to provide Underwriters with as much detail as possible with regard to evaluation of the insurance