Complete 0%
1 Proposer Information 2 Declaration
Name of Company *
Physical Address
Physical Code
Registration Number
VAT Number Numbers only
Business Description/Industry
Years entity has traded (uninterrupted) Numbers only
Retroactive Date (if applicable)

Subsidiary Information

1. Name of Company
2. Name of Company
1. Registration Number
2. Registration Number

Staff Resources

Number of Employees (All employees, directors and officers including subsidiaries)

Risk Questions

Please confirm that the following statements are TRUE, by ticking the box.

1. EACH company named above...
IS a Private Company
IS domiciled in South Africa
HAS an MOI that prohibits it from offering any of its securities to the public
HAS the same or similar business objective in terms of its products or services
2. EACH company named above IS NOT...
a Bank or Deposit taking Institution
a business providing Proprietary Investments Products and Services
an Insurance or Reinsurance business (but excluding insurance intermediaries, advisors, managers and administrators)
a Hedge Fund, Collective Investment product supplier or equivalent
a Stock broker or Stock Exchange
3. EACH company named above has Annual Financial Statements for the past two financial years (AFS)...
which have been approved by shareholders in terms of an Annual General Meeting of Shareholders
which have been audited or reviewed in the past 15 months
that do not contain a qualified auditor opinion
that confirm Total Assets exceed Total Labilities
that confirm Current Assets exceed Current Liabilities
that do not record a negative Net Operating Profit after Tax
4. EACH company named above IS NOT...
applying for or considering any Business Rescue proceeding
contemplating or facing any litigation
operating any repayment plan with any creditor
5. EACH company named above HAS NOT...
had a claim made NOR AWARE of any circumstance that could give rise to a claim being made against the company or any director or officer as contemplated in the companies Act 2008
6. EACH company named above IS NOT AWARE...
of any services or products supplied in any Sanctioned Territory or to any Sanctioned Person as listed by the United Nations, the European Union, the Federal Republic of Germany, the United Kingdom or the United States of America
7. EACH company named above HAS NOT...
undergone and is NOT PLANNING any merger, acquisition, disposal or similar corporate action in the past 24 months or future 24 months
8. EACH company named above HAS NEVER...
had any application for insurance declined NOR EVER HAD any insurance cancelled

Cover You Require

Limit if Indemnity Options

Rand Value Numbers only
Rand Value Numbers only
Rand Value Numbers only
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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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