Commerical Crime Insurance


Complete 0%
1 Proposer Information 2 Declaration
1. Name of Proposer *
2. Physical Address
Physical Code
3. Full description of business activities
4. VAT Number Numbers only

5. State the total number of employees in each of the below categories. If employees fall into more than one category they should be included once only.

5.1. Management, Admin, Technical etc (White Collar) Numbers Only
5.2. Labourers etc (Blue Collar) Numbers Only
5.3. Contracted Employees (if you want these covered) including Casual Labour, Guards etc Numbers Only
5.4. Total of all above Numbers Only
6. Give details of your screening process for new employees
7. Have any of your employees been dismissed for dishonesty during the last 12 months?
7.1. If Yes, give details for each dismissal
8. Do you deposit cash and cheques daily?
9. Do all cheques require two signatures?
10. Describe your stock (separately for raw materials and finished goods, if applicable)
11. What is the highest value of any individual item of stock? Name the item.
12. By whom and how often are stock-takes done?
13. What is the maximum permissible Rand value per individual electronic transaction? Numbers Only
14. Is dual authority for electronic financial transactions always required?
15. What procedures are in place to control the creation of new payees and all changes to payee details?
16. Has any insurer ever cancelled or refused to accept or continue any Fidelity Guarantee or Commercial Crime Insurance or imposed special conditions?
16.1. If Yes, give particulars

17. During the last five 5 years did you suffer direct financial loss as a result of:

17.1. Fraud by or dishonesty of an employee?
17.2. Any form of computer crime?

18. If your answer is YES to either 17.1 or 17.2 above, please provide information for each of the losses below.

18.1. Amount Numbers Only
18.1. When Committed
18.1. When Discovered
18.1. Type of Loss
18.2. Amount Numbers Only
18.2. When Committed
18.2. When Discovered
18.2. Type of Loss
18.3. Amount Numbers Only
18.3. When Committed
18.3. When Discovered
18.3. Type of Loss
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Complete 50%
1 Proposer Information 2 Declaration

I/We the undersigned duly authorised person(s) declare that:

  1. I am/we are authorised by each of the Insureds to sign this Proposal Form.
  2. The above statements are correct, true and complete.
  3. No information material to this Proposal Form has been withheld.
  4. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure.
  5. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure.
  6. Apart from what is disclosed in this document, I/we are not aware of any request for records being made by a patient, family member of a patient, or an attorney nor have I/we received a letter from an attorney regarding treatment which was provided to a patient.
  7. Apart from what is disclosed in this document, I/we are not aware of any circumstance which might reasonably lead to a claim or suit being lodged against me, regardless of whether I/we view that suit to be without merit.
  8. I/we understand that no insurance is in force until such time as the Insurer has confirmed acceptance of the proposed insurance.
  9. I/we undertake to inform the Insurer of any material alteration to these facts occurring before completion of the contract of insurance.
  10. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.
  11. I/we acknowledge that the signing of this proposal form binds neither myself to accept the subsequent quote, nor does it bind the Insurer to accept the proposal. It is agreed that all written statements and attachments furnished to the Insurer in conjunction with this proposal are hereby incorporated by reference into this proposal and made part thereof.
  12. Except where indicated to the contrary, I/we understand that any statement made in this Proposal Form will be treated by the Insurer as a statement made by all persons to be insured.
I Agree*
First Name *
Surname *
Date *
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