Professional Indemnity Proposal Form for Accountants & Auditors

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Oliver McCarthy
8 years ago
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1 Tel: (011) / Cell: / Fax: Loch Avenue, Parktown, Johannesburg, 2193 P.O. Box 31729, Braamfontein, 2017 admin@khanyisabrokers.co.za Professional Indemnity Proposal Form for Accountants & Auditors This is a proposal for a claims made policy The policy will only respond to claims and/or circumstances, which are first made against the Insured and notified to the Insurer during the policy period. The policy will not provide cover for:- Events that occurred prior to the retroactive date of the policy. Claims made after the expiry of the policy period even though the Wrongful Act giving rise to the claim may have occurred during the policy period. Claims notified or arising out of facts or circumstances notified under any previous policy or noted on the current proposal form or any previous proposal form. Claims made, threatened or intimated prior to the commencement of the policy period. Facts or circumstances in your knowledge prior to the policy period, which you knew had the potential to give rise to a claim under the policy. DISCLOSUE You must disclose to the Insurer 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. ATTACHMENTS When in doubt disclose Before you return this form, have you included the following (please indicate by ticking the boxes): Company brochure/ additional information: Claims information (if relevant): Please attach details where not enough space on the proposal Company egistration Number: 2006/035498/07 VAT egistration Number: An Authorised Financial Services Provider: License Number BEE ating

against the Insured and notified to the Insurer during the policy period. The policy will not provide cover for:- Events that occurred prior to the retroactive date of the policy.

2 1. Details of Proposed Insured; Professional Indemnity Proposal a. Insured / Practice Name : (Please attach details of all subsidiary companies) b. Postal Address: c. Telephone Number : Fax : d. address: Web Site: e. VAT egistration No : _ f. Present Legal Constitution (Mark elevant Box) Sole Practitioner Partnership Incorporated Co. Limited Co. Closed Corp. g. Date of commencement of Practice : As currently constituted : As initially established : h. 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 I. Are any branches of the Proposed Insured located outside of South Africa? Yes / No

Date of commencement of Practice : As currently constituted : As initially established : h. Names and Qualifications of Principals. I. In case of Partnerships Partners II.

3 2. Detailed Business Description: (if engaged in multiple disciplines, please provide a percentage split total must add up to 100) 3. Claims experience a. Have any claims ever been made against the proposed Insured / Partners / Directors / members or Employees for the type of cover for which you are now applying, whether in terms of this Proposal or any other Proposal / Policy for the same type of cover? Yes / No b. After enquiry, are any of the Proposed Insured / Partners / Directors / Members or Employees aware of any circumstances which would be covered under a policy of this type, or any other Policy for the same type of cover, that may result in any claims or any possible claims being made against them? Yes / No c. Please provide the claim numbers for those claims already registered with SHA. 4. Details of Insurance a. Are you at present of have you in the past been Insured? Yes / No If yes, please provide the following details: Name of Insurers : Date cover expires/d : Expiry of un-off cover (if any) : Limit of Liability : Excess applicable :

any other Proposal / Policy for the same type of cover? Yes / No b.

4 b. 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? Yes / No II. required an increased premium or imposed special terms? Yes / No III. cancelled an Insurance? Yes / No c. 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? Yes / No 5. Staff complement Total Number of : Partners / Principals / Directors Professional Staff (Other than above) All Other Staff Total 6. Approximate percentage of estimated gross income accruing from various activities Approximate Percentage 6.1 Auditing Fees 6.2 Accounting and Secretarial 6.3 Taxation only 6.4 Management Consultancy 6.5 Other Consultancy (Please provide full details) 6.6 Share egistration 6.7 Executors and Trusteeship 6.8 Voluntary Liquidations 6.9 Insolvencies, Compulsory Liquidations, Judicial Management & eceiverships 6.10 Deceased Estates 6.11 Sequestrations 6.12 Curatorships 6.13 Business ecovery / escue 6.14 Other Activities (Please provide full details) 100

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? Yes / No 5.

5 7. Please provide the following details where services are rendered through other companies (if any) Details of Companies Name of Company Directors Activities Annual Income Of the Company Accruing to the Insured Ownership Details of any financial interest in any Company named above, of any person other than a nominee of the partners of the Insured. Management and Control Name of Partner responsible for activities of each company Does any Company employ staff directly? Yes / No Any functions of the Company exercised exclusively by partners / employees of the Insured? Clientele and contractual relationships Does any Company: a) offer its services (directly or through the Insured) to persons who are NOT clients of the Insured? Yes / No O b) enter into direct contractual relationships with clients? Yes / No 8. Please provide the following details in respect of business conducted outside South Africa. 8.1 Do you or your firm do any business for your clients in the U.S.A, Canada or any other countries / states governed by their laws? Yes / No If Yes, how many visits have been made to these countries / states during the last 12 months? 8.2 How many working days have been spent in there in the last 12 months? 9. Inter partnership arrangements 9.1 Do you have any inter-partnership arrangements with other Accountants, or firms of Accountants? Yes / No

1 Name of Partner responsible for activities of each company. 7.3.2 Does any Company employ staff directly? Yes / No 7.3.3 Any functions of the Company exercised exclusively by partners / employees of the Insured?

6 9.2 If yes, do these firms carry out work in the name of your firm or vice-versa? Yes / No 9.3 Do they have a similar professional indemnity policy and for what Limit of Indemnity? Yes / No 9.4 If they carry out work in your name, please submit a declaration from them that their partners are, after enquiry, not aware of any circumstances which may result in any claim being made in connection with work undertaken on your behalf. 10. Fee income (as at the company s financial year end) Please give the audited fees for the past 5 years: Year End Fees Year End Fees Estimate for next 12 months 11. Quotations required 11.1 Limit any one period of insurance 11.2 Deductible (Excess) inclusive of costs and expenses. (The amount carried by Insured per claim) 11.3 Do you require a quote on one or two reinstatements of the Limit during the period of Insurance? Yes / No Declaration: I/we declare that after proper enquiry the statements and particulars given above are true and that I/we have not missstated or suppressed any material fact. I/we agree that this Proposal Form, together with any other material information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/we undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract. Signed on behalf of Insured Full name Position held at Insured Date

4 If they carry out work in your name, please submit a declaration from them that their partners are, after enquiry, not aware of any circumstances which may result in any claim being made in

Architects, Interior Designers & Town Planners

POPOSAL FOM POFESSIONAL INDEMNITY Architects, Interior Designers & Town Planners This is a proposal for a claims made policy The policy will only respond to claims and/or circumstances, which are first