LIABILITY INSURANCE

General Public Liability | Pollution Liability | Product Liability (including Defective Workmanship) | Employers Liability | Product Recall

 

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1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

General Public Liability | Pollution Liability | Product Liability (including Defective Workmanship) | Employers Liability | Product Recall


Details of Proposed Insured

1. Name of Firm (Your legal entity – please be accurate – to be used on your policy contract) *
2. Contact Person *
3. Address
Suburb
City
Province/State/Region
Physical Code
4. Tel No 011 000 1234
6. Email *
8. Company Registration No
5. Cell No *011 000 1234
7. Website
9. VAT No Numbers only

10. Date of commencement of Practice:

10.1. As currently constituted *
10.2. As initially established
11. Subsidiary Firms and Offices (provide name, city and country):

12. List the Countries outside South Africa where Business activities are undertaken

12.1. Country
12.2. Approximate Percentage of Turnover
12.2. Country
12.2. Approximate Percentage of Turnover
12.3. Country
12.3. Approximate Percentage of Turnover

Detailed Business Description

Please provide a detailed business description.  Please be accurate - your policy contract is based on this information.
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Complete 6%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Claims Experience

1. Have you during the past 5 years had a Liability claim made against you?
Yes
No
None
2. Are you aware, after enquiry, of any circumstances that may give rise to a Liability claim being made against you?
Yes
No
None
3. If Yes to any above, please advise full factual details confirming when the claim or circumstance arose, describing the circumstances of the claim, the values involved and the present status of the claim or circumstance.  Please do not express any view as to whether or not you have a liability in respect of any matter not settled.

Details of Insurance

1. Do you at present or have you in the past had Liability insurance cover?
Yes
No
None
1.1. If Yes, in order for us to provide continuity of insurance cover and to maintain the Retroactive Date, please attach a copy of your current policy and/or schedule.
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2. For the type of Insurance now being proposed, has any Insurer ever:

2.1. Declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
2.2. Required an increased premium or imposed special terms?
Yes
No
None
2.3. Cancelled an insurance?
Yes
No
None
2.3. If yes, please provide full details:
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Complete 13%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration
Do you require Pollution Liability cover?*
Yes
No
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Complete 20%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Pollution Liability - Sudden and Accidental

Not related to Products or Defective Workmanship. Liability arising out of the escape of any gas liquid, substance or noise that is sudden, unintended and unexpected and occurs at a specific time and place.

1. How and where do you dispose of waste and effluent related to your business?
2. Is any waste/effluent of a toxic nature?
Yes
No
None
2.1. If Yes, please advise full details.
3. Have you been prosecuted in the last 5 years for contravention of any statute or law relating to the release from any premises or elsewhere of a substance into sewers, rivers, sea, air or land?
Yes
No
None
3.1. If Yes, please advise full details.
4. Have any claims or complaints been made against you resulting from sudden and accidental pollution?
Yes
No
None
4.1. If Yes, please advise full details.
5. Limit of Indemnity Required (Rands) Numbers in Rands
6. Deductible Required (Rands) Numbers in Rands
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Complete 26%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration
Do you require Product Liability cover?*
Yes
No
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Complete 33%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Product Liability (Including Defective Workmanship) 

Your legal liability to pay compensation to a Third-Party including Costs and Expenses arising out of your Business following Third-Party injury and/or property damage arising out of your product and resultant accidental pollution

1. In the section below, please provide the following:

  • Please provide a list of product types manufactured, produced, supplied or distributed and to which this insurance is to apply.
  • List the Countries outside South Africa where Business activities are undertaken with regards to your products.
  • List the Countries outside South Africa to which your products are exported.
1.1. List of Product Types
1.1. % of Total Turnover Numbers Only
1.1. Date first marketed
1.1. Countries: Business activities outside RSA.
1.1. Countries: Exported to.
1.2. List of Product Types
1.2. % of Total Turnover Numbers Only
1.2. Date first marketed
1.2. Countries: Business activities outside RSA.
1.2. Countries: Exported to.
1.3. List of Product Types
1.3. % of Total Turnover Numbers Only
1.3. Date first marketed
1.3. Countries: Business activities outside RSA.
1.3. Countries: Exported to.
2. Will any new type of product be marketed during the next 12 months?
Yes
No
None
2.1. If yes, please give details:
3. Do you have any power of attorney or asset in the USA/Canada?
Yes
No
None
3.1. If Yes, please give details:
4. Is the USA/Canada seller or supplier insured for products liability including imported goods?
Yes
No
None
4.1. If Yes, please give full details including amounts involved.
5. Limit of Indemnity Required (Rands) Numbers in Rands
6. Deductible Required (Rands) Numbers in Rands
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Complete 40%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration
Do you require Defective Workmanship Liability cover?*
Yes
No
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Complete 46%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Defective Workmanship Liability

Liability arising out of the physical act of treating, installing, servicing, altering, repairing, or working on any tangible property including related gratuitous advice and resultant accidental pollution

1. Please give full details and provide the estimated annual turnover from each such activity.
2. Limit of Indemnity Required (Rands) Numbers in Rands
3. Deductible Required (Rands) Numbers in Rands

Sanctions

No indemnity may be granted by insurers in respect of any business activities undertaken by the proposer in a SANCTION TERRITORY or with a SANCTIONED PERSON as listed by the United Nations, the European Union, the United Kingdom or United States of America.

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Complete 53%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Quality Control & Raw Ingredients

1. Where does the proposer obtain their raw ingredients from?
2. What quality control procedures are in place to check the raw ingredients?
3. What quality control procedures are in place to check the products before they are sent out?
4. Does the proposer label the products?
Yes
No
None
4.1. If Yes, what quality control procedures are in place to check that the information on the labels are correct and that the correct label is attached to the correct product?
5. Additional details on the quality control procedures.
6. Are full rights of recourse maintained against suppliers and manufacturers?
Yes
No
None
6.1. If No, please explain:
7. Limit of Indemnity Required (Rands) Numbers in Rands
8. Deductible Required (Rands) Numbers in Rands
9. Do you have a Product Recall plan in place? This question is asked for the purpose of assessing and evaluating the product risks and exposures.  
Yes
No
None
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Complete 60%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration
Do you require Employers Liability cover?*
Yes
No
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Complete 66%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Employers Liability

Liability arising out of a claim by a person employed under a contract of employment or apprenticeship with you that you have caused them injury arising out of such employment (subject to any worker’s compensation legislation).

1. Are your employees protected from machinery, plant, noise, toxins or any other specific conditions associated with your Business?
Yes
No
None
1.1. If No, please explain:
2. Have you been prosecuted under the Health and Safety Act or any other relevant Statute or Regulation?
Yes
No
None
2.1. If Yes, please explain:
3. Limit of Indemnity Required (Rands) Numbers in Rands
4. Deductible Required (Rands) Numbers in Rands
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Complete 73%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration
Do you require Product Recall Cover cover?*
Yes
No
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Complete 80%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Product Recall Cover

Your decision during the Insurance period, with Our prior written approval, to recall Your Product which is likely to cause Injury or Damage for which You may become legally liable

1. In the section below, please provide the following:

  • Please provide list of product types and turnover (excluding VAT) manufactured, produced, supplied or distributed and to which this insurance is to apply. 
  • List the Countries outside South Africa where Business activities are undertaken with regards to your Products.
  • List the Countries outside South Africa to which your Products are exported.
1.1. List of Product Types
1.1. Total Turnover Numbers Only
1.1. Date first marketed DD/MM/YYYY
1.1. Countries: Business activities outside RSA.
1.1. Countries: Exported to.
1.2. List of Product Types
1.2. Total Turnover Numbers Only
1.2. Date first marketed DD/MM/YYYY
1.2. Countries: Business activities outside RSA.
1.2. Countries: Exported to.
1.3. List of Product Types
1.3. Total Turnover Numbers Only
1.3. Date first marketed DD/MM/YYYY
1.3. Countries: Business activities outside RSA.
1.13 Countries: Exported to.
2. Will any new type of product be marketed during the next 12 months?
Yes
No
None
2.1. If Yes, please give details:
3. What plans exist to initiate a recall? If none, please advise why not?
4. Would it be necessary for any other party to co-operate with initiating a recall? Example: manufacturer, producer, supplier or distributer.
Yes
No
None
4.1. If Yes, please give full details:
5. If any of the proposer’s products are incorporated into other products would the other manufacturer(s) initiate a recall?
Yes
No
None
5.1. If Yes, please provide details:
6. Have press or other announcements been prepared for retention on file?
Yes
No
None
6.1. If No, please advise why not?

7. Do the products carry:

7.1. The proposer’s company name?
Yes
No
None
7.2. The proposer’s trademark?
Yes
No
None
7.3. A part number(s)?
Yes
No
None
7.4. A product batch number?
Yes
No
None
8. Details of records maintained to trace location of products.
9. How long are records kept?
10. What is the proposer’s estimate of the likely cost of a recall within the next 12 months?

11. Name (s) and position(s) of personnel within the proposer’s organisation empowered to authorize a recall.

11.1. Name & Surname
11.1. Position
11.2. Name & Surname
11.2. Position
11.3. Name & Surname
11.3. Position
11.4. Name & Surname
11.4. Position
12. Are you currently Insured for Products Recall Insurance?
Yes
No
None
12.1. If Yes, in order for us to provide continuity of Insurance cover and to maintain the Retroactive date, please attach a copy of your current policy and/or schedule.
Drag & Drop Files Here Browse Files

13. In respect of your Products Recall cover, has any Insurer ever:

13.1. Declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
13.2. Required an increased premium or imposed special terms?
Yes
No
None
13.3. Cancelled an insurance policy?
Yes
No
None
13.3. If Yes, please provide full details: 
14. Have you, during the past 5 years, had a Product Recall claim made against you?
Yes
No
None
15. Are you aware, AFTER ENQUIRY, of any circumstances that may give rise to a Product Recall claim being made against you?
Yes
No
None
15.1. If Yes, please provide full details:
16. Limit of Indemnity Required (Rands) Numbers in Rands
17. Deductible Required (Rands) Numbers in Rands

Sanctions

No indemnity may be granted by insurers in respect of any business activities undertaken by the proposer in a SANCTION TERRITORY or with a SANCTIONED PERSON as listed by the United Nations, the European Union, the United Kingdom or United States of America.

Summary of Cover

Recall Expenditure: any reasonable amounts You need to spend in relation to Recall for:

  • Media communication and correspondence.
  • Transportation in connection with the return of Your product or any part thereof to You or your nominated agent.
  • Destroying Your Product except where such costs are greater than transportation costs.
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Complete 86%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 Declaration

Your Financial Declaration (as at the company’s financial year end)

1. What is your Financial Year End date?

2. Please provide your audited or equivalent figures (excluding VAT) as at your three financial year ends:


2.1. Period From
2.1. Period To
2.1. Turnover (Excl USA/Canada) Numbers in Rands
2.1. Turnover (USA/Canada only) Numbers in Rands
2.1. Total Turnover (Incl USA/Canada) Numbers in Rands
2.2. Period From
2.2. Period To
2.2. Turnover (Excl USA/Canada) Numbers in Rands
2.2. Turnover (USA/Canada only) Numbers in Rands
2.2. Total Turnover (Incl USA/Canada) Numbers in Rands
2.3. Period From
2.3. Period To
2.3. Turnover (Excl USA/Canada) Numbers in Rands
2.3. Turnover (USA/Canada only) Numbers in Rands
2.3. Total Turnover (Incl USA/Canada) Numbers in Rands

2.4. Estimated turnover next 12 months 

2.4. Turnover (Excl USA/Canada) Numbers in Rands
2.4. Turnover (USA/Canada only) Numbers in Rands
2.4. Total Turnover (Incl USA/Canada) Numbers in Rands
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Complete 93%
1 Step 1 2 Step 2 3 Pollution Liability Select 4 Pollution Liability 5 Product Liability Select 6 Product Liability 7 Defective Workmanship Liability Select 8 Defective Workmanship Liability 9 Quality Control & Raw Ingredients 10 Employers Liability Select 11 Employers Liability 12 Product Recall Cover Select 13 Product Recall Cover 14 Financial Declaration 15 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*
Yes
First Name *
Surname *
Date *
Submit
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