PrOFESSIONAL INDEMNITY

 

If you prefer to download the form, please CLICK HERE.

 

It is the duty of the Proposer to disclose all material facts to Underwriters. Where this is omitted, the Underwriters may avoid their obligation under the Policy.
For the purposes of the Proposal and for all purposes relating to any policy issued pursuant to this Proposal, a ‘material fact’ shall be deemed to be one that would be likely to influence an Underwriter’s judgment and acceptance of your Proposal. 

 

Complete 0%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration
Insured/Practice Name *
Contact Person *
Address
Suburb
City
Province/State/Region
Physical Code
Tel No 011 000 1234
Email *
Company Registration No
Cell No *011 000 1234
Website
VAT No Numbers only
Present Legal Constitution*
Sole Practitioner
Partnership
Incorporated Co
Limited Co
Closed Corp
Other

Date of commencement of Practice:

As currently constituted *
As initially established
Are any branches of the proposed insured located outside of South Africa?
Yes
No
None
If yes, please provide full details:

Names and Qualifications of Principals (attach ID copies below)

Name
Date Qualified
Qualifications
Name
Date Qualified
Qualifications
Name
Date Qualified
Qualifications
Upload ID Copies Max Size 10MB. 10 Files Max
Drag & Drop Files Here Browse Files
Back Next Save Progress
Complete 5%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration
1. 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
None
1.1. If yes, please provide full details:
2. 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 that may result in any claims or any possible claims being made against them?
Yes
No
None
2.1. If yes, please provide full details:
Back Next Save Progress
Complete 11%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration
What is the date of the Company’s financial year-end:

Please give the audited fees for the last 5 completed financial years (which must include contingency fees):

Year End 2019 Fees Numbers with No Spaces
Year End 2022 Fees Numbers with No Spaces
Year End 2020 Fees Numbers with No Spaces
Year End 2023 Fees Numbers with No Spaces
Year End 2021 Fees Numbers with No Spaces
Estimate for the next 12 months Numbers with No Spaces
Back Next Save Progress
Complete 16%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration
Profession
Back Next Save Progress
Complete 22%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Attorneys

Detailed Business Description

1. Approximate percentage of estimated gross income accruing from various activities.

Total must add to 100%.

Conveyancing % Numbers Only
Deceased Estates % Numbers Only
Criminal % Numbers Only
M.V.A % Numbers Only
Business Recovery/Rescue % Numbers Only
Commercial % Numbers Only
Curatorship’s % Numbers Only
Matrimonial % Numbers Only
National Housing Board % Numbers Only
Medical Malpractice Litigation  % Numbers Only
Probate % Numbers Only
Intellectual Property % Numbers Only
Patents % Numbers Only
Sequestrations % Numbers Only
Other Activities % Numbers Only
If Other, please provide full details:

2. Business conducted outside South Africa.

2.1. Do you or your firm do any business for your clients in the U.S.A, Canada, Australia or any other countries/states governed by their laws? 
Yes
No
None

If yes, please provide the following details:

2.1.A. What percentage of your fees is attributable to these activities? Numbers Only
2.1.B. Do you have physical offices in these areas? 
Yes
No
None
2.2. Does the company or any partner, Director, etc. own any assets in the U.S.A, Canada or Australia?
Yes
No
None

3. Inter partnership arrangements.

3.1. Do you have any inter-partnership arrangements with other Attorneys, or firms of Attorneys? 
Yes
No
None
3.1.A. If yes, do these firms carry out work in the name of your firm or vice-versa?
Yes
No
None
3.1.B. Do they have professional Indemnity cover in place?
Yes
No
None
3.1.C. If they have professional Indemnity cover in place, for what limit? Numbers Only
3.1.D. If they carry out 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.
Drag & Drop Files Here Browse Files

Previous Insurance Cover

4. Other than the cover afforded under the Legal Practitioners Insurance Indemnity Fund (LPIIF previously AIIF), do you at present or have you in the past had any other policy(ies) of this type of Insurance cover in place? (This includes any “Top-Up” cover over and above the LPIIF cover).
Yes
No
None

4.1. If yes, please provide the following details:

4.1.A. Name of Insurer
4.1.B. Date cover expires(d)
4.1.C. Limit of Liability
4.1.D. Retroactive Date
4.1.E. Current Premium
Back Next Save Progress
Complete 27%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Misappropriation Of Trust Funds Cover

Misappropriation Of Trust Funds covers you for theft of third party money from your trust account by an employee.

ALL claims arising out of the theft of trust money are not always included in a Professional Indemnity policy, i.e. misappropriation of trust money by staff might be excluded.  This applies to both AIIF and Top-up cover.  It is therefore essential that all practitioners with trust accounts purchase Misappropriation of Trust Funds policies. 


Do you require cover for Misappropriation of Trust Funds?*
Yes (Click NEXT to fill in info)
No (you will be directed to the next section)
Back Next Save Progress
Complete 33%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Misappropriation Of Trust Funds Cover

1. Risk Management

1.1. Are criminal and credit checks performed on new employees before they are hired?
Yes
No
None
1.2. Does the firm enforce an employee leave policy which requires its employees to take a minimum of five consecutive days in a calendar year? 
Yes
No
None
1.3. Do you have a “segregation of duties policy” with regards to processing, loading, releasing and authorising payments and electronic funds transfers? 
Yes
No
None
1.4. Does the firm have a policy in place to ensure that a payee’s details are verified with the actual account holder before making payment?
Yes
No
None
1.5. Are procedures in place to control the creation of new payees and changes to existing payees?
Yes
No
None
1.6. Are bank details always confirmed telephonically and a record kept of the confirmation?
Yes
No
None
1.7. Are all bank tokens and bank access cancelled on the termination of an employee’s employment within the firm?
Yes
No
None
1.8. Is computer access revoked on the termination of an employment within the firm?
Yes
No
None
1.9. Are all cheques and/or cash which are received by the firm banked daily?
Yes
No
None
1.9.A. If no, please indicate the length of time it takes to bank the relevant monies.
1.10. Do you retain proof of EFT payments and return paid cheques from the banks?
Yes
No
None
1.11. Do you provide receipts for all trust payments received? If no, please advise what process of recording is used?
Yes
No
None
1.12. If you have answered NO to any of the above questions, please provide additional information as to what alternative processes you may have in place.

2. In respect of Trust Money, please indicate the amount of Trust Money held at the Financial Year End for the last three years.

2.1. Amount Held in Trust as at Year End 2021 (Rands) Numbers Only
2.2. Amount Held in Trust as at Year End 2022 (Rands) Numbers Only
2.3. Amount Held in Trust as at Year End 2023 (Rands) Numbers Only

3. At what intervals are Trust Money balances checked by?

3.1. An internal audit of one of the Partners?
3.2. An audit by the firm’s Auditors? 
4. Please tick the system used to manage your Trust Fund Account
Nedbank Corporate Saver
Nedbank Pro Banker
First National Bank
Standard Bank Third Party Fund Administration
Investec Corporate Cash Manager
Other
None
4.1. If Other, please specify.
5. Basis of Cover
Blanket Basis
Named Persons/Position Basis
None

5.1. If cover is selected on a Named Person Basis or Named Position Basis, then please provide a list of the staff to be covered under this section of the policy.

5.1.A Employees Name
5.1.B Employees Position
5.2.A Employees Name
5.2.B Employees Position
5.3.A Employees Name
5.3.B Employees Position

5.4. Optional Misappropriation of Trust Fund Extensions (to be charged for)

5.4.1 Insolvency Practitioners extension
Yes
No
None
Back Next Save Progress
Complete 38%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Commercial Crime (Including Fidelity Guarantee)

Commercial Crime covers you for theft of own money or property, or for which you are responsible, resulting directly from any dishonest or fraudulent act of an employee.  The cover further extends to Computer Fraud/Computer Virus/Electronic Data Loss/Extortion/Fraudulent Transfer Instructions etc.


Do you require cover for Commercial Crime?*
Yes (Click NEXT to fill in info)
No (you will be directed to the next section)
Back Next Save Progress
Complete 44%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Commercial Crime (Including Fidelity Guarantee)

1. Limit of Indemnity to be quoted on.

1.1. Rand Numbers Only
1.2. Rand Numbers Only
1.3. Rand Numbers Only
2. Basis of Cover
Blanket Basis
Named Persons/Position Basis
None

2.1. If cover is selected on a Named Person Basis or Named Position Basis, then please provide a list of the staff to be covered under this section of the policy.

2.1.A Employees Name
2.2.A Employees Name
2.3.A Employees Name
2.1.B Employees Position
2.2.B Employees Position
2.3.B Employees Position

3. Optional FG Extension (to be charged for)

3.1. Retroactive cover extension - No previous insurance in force
Yes
No
None
3.2. Superseded insurance extension
Yes
No
None
3.3. Voluntary first amount payable clause
Yes
No
None
3.4. Reduction/reinstatement of insured amount clause
Yes
No
None
3.5. Costs of recovery extension
Yes
No
None
3.6. Computer losses extension
Yes
No
None
3.7. Extension for losses discovered more than 24 (twenty-four) months after being committed but not more than 36 (thirty-six) months thereafter
Yes
No
None
3.8. Extension granted on receipt of a satisfactory system audit in respect of losses discovered more than 24 (twenty-four) months after being committed (if stated in the schedule to be included)
Yes
No
None
Back Next Save Progress
Complete 50%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Third Party Impersonation Fraud Cover

Third Party Impersonation Fraud covers you for direct financial loss sustained as a result of an employee transferring money in good faith from a company’s accounts as a result of a fraudulent instruction.


Do you require cover for Third Party Impersonation Fraud Cover?*
Yes (Click NEXT to fill in info)
No (you will be directed to the next section)
Back Next Save Progress
Complete 55%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Third Party Impersonation Fraud Cover

1. Please choose between OPTION 1 or OPTION 2
Option 1
Option 2
None

Option 1

 

Covers loss of Money resulting directly from an Insured Employee having, in good faith:
1. Amended the bank details of the Insured’s client to the details of a bank account that belongs to an Impersonator (‘incorrect bank account”); and 
2. Transferred Money from the Insured’s Trust account into the incorrect account. 


As a result of a fraudulent instruction communicated via email, telephone or fax to the Insured Employee, by an Impersonator purporting to be the Insured’s Client or Authorised Person in respect of a transaction being acted upon by the Insured.

 

The Excess payable by the Insured and the Indemnity provided by the Insured are dependent upon the level of Verification undertaken by the Insured Employee following the receipt of a fraudulent instruction to change bank details.

 

Please provide:

A copy of the firms Verification Policy and register of employees who have acknowledged either receiving a copy of, or being trained on, the Verification Policy.
Drag & Drop Files Here Browse Files
A list of Insured employees who are to be covered under this section of cover.

Option 2

 

Underwritten by Commercial Crime Concepts (*Business & Trust funds)


Covers loss of money belonging to the Insured or which is in the Insured’s care, custody and control; resulting directly from an insured Employee having, in good faith:


1. Transferred money from the Insured’s own account; or 

2. Amended the bank details of a customer, supplier or service provider in the Insured’s EFT payment system as a result of a fraudulent instruction (via e-mail, telephone or fax), communicated to an employee of the Insured, by a person purporting to be:

2.1. A director, officer, partner, member or sole proprietor of the Insured or other employee of the Insured; or 

2.2. A customer, supplier, service provider or adviser, or a representative or employee of such person or entity, that has a legitimate written agreement or a pre-existing written agreement or agreement to provide goods or services to the Insured.

Back Next Save Progress
Complete 61%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Building Industry

1. Details of Insurance

1.1. Are you at present of have you in the past been Insured?
Yes
No
None

If yes, please provide the following details:

1.1.A. Name of Insurers
1.1.B. Date cover expires/d
1.1.C. Retroactive date
1.1.D. Limit of Liability
1.1.E. Current Premium Numbers Only

1.2. For the type of Insurance now being proposed, has any Insurer ever:

1.2.A. Declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
1.2.B. Required an increased premium or imposed special terms?
Yes
No
None
1.2.C. Cancelled an Insurance?
Yes
No
None
2. Detailed Business Description

2.1. Disciplines in which engaged.

Please provide the percentage of total fees attributable to each profession. Total percentage must add up to 100%.

2.1.A. Civil % Numbers only
2.1.D. Chemical and Process % Numbers only
2.1.G. Mechanical % Numbers only
2.1.J. Quantity Surveying % Numbers only
2.1.B. Environmental % Numbers only
2.1.E. Electrical Engineering % Numbers only
2.1.H. Architecture % Numbers only
2.1.K. Mining % Numbers only
2.1.C. Structural Engineering % Numbers only
2.1.F. Project Management % Numbers only
2.1.I. Geotechnical % Numbers only
2.1.L. Land Surveying % Numbers only
2.1.M. Other (Please Specify)

3. Supervision, No Construction

3.1. Are you involved in Project Management?
Yes
No
None
3.1.A. If yes, please check the activities you are responsible for and answer the questions that follow.
Administration of Retention Fund
Approval of Detailed Design
Arranging Site Insurances
Authorisation of Progress Payments
Cash Flow Forecasts
Certifying Final Completion
Certifying Final Payment
Clearing, Forwarding & Customs Clearance Duties
Co-ordination
Cost Estimates
Design Criteria
Drafting of Contract Conditions
Expediting
Feasibility Studies (General)
Flowsheets
Geotechnical Services
Instructions to Tenderers
Issuing Variation Orders
Measurement
Quality Control/Assurance
Quantity Estimates
Road Routing Design and Feasibility
Settling Contractual Claims
Supervision of Commissioning
Supervision of Installation/Construction
Tender Adjudication/Recommendation
Working Drawings
Others
None
3.1.B. If Others, Please Specify
3.2. Please provide us with details of any other projects being worked on of an unusual or special nature (outside the normal scope of business) or with a total contract value in excess of R 500M?

3.3. Tidal Waters (ocean, coastal, river mouth or estuarine waters coming under the continual influence of the tides)

3.3.1. Is or will your practice operate or undertake any projects that could be affected by tidal Waters?
Yes
No
None
3.3.2. Is or will your practice operate or undertake any projects on reclaimed coastal land?
Yes
No
None

3.3.3. If yes, please provide the following information:

3.3.3.A. Are these projects normal to your business practice?
Yes
No
None
3.3.3.B. What is your experience in this discipline?
Yes
No
None
3.3.3.C. Do you employ the necessary specialists within your practice?
Yes
No
None
3.3.3.D. Are the techniques used tried and tested or new?
Yes
No
None
3.3.3.E. Advise the anticipated Fees from such projects.  Numbers Only
3.3.3.F. Advise any previous losses/circumstances.
4. Is the Practice or any Partner/Principal/Director engaged with any other person/Practice in a Single Project Partnership or a Consortium or Group Practice?
Yes
No
None
4.1. If Yes,  please provide details:

The Company’s standard policy does not cover any liability that may flow from collaboration in Consortium or Single Project partnership, and notice must be given any of any such association that may be entered into during the contract subsistence of the Insurance contract.

5. Please provide the following contract details:

5.1. Does this Practice undertake any work whatsoever where the “end product’ of such work is carried out in territories other than Republic of South Africa?
Yes
No
None
5.2.A. Country
5.2.B. Starting Date
5.2.C. Type of Contract
5.2.D. Total Contract Value (R) Rands (Numbers Only)
5.2.E. Approximate Completion Date
5.3.A. Country
5.3.B. Starting Date
5.3.C. Type of Contract
5.3.D. Total Contract Value (R) Rands (Numbers Only)
5.3.E. Approximate Completion Date
5.4.A. Country
5.4.B. Starting Date
5.4.C. Type of Contract
5.4.D. Total Contract Value (R) Rands (Numbers Only)
5.4.E. Approximate Completion Date

5.5. Please state the 5 largest contracts commenced during the past 6 years:

5.6.A. Country
5.6.B. Starting Date
5.6.C. Type of Contract
5.6.D. Total Contract Value (R) Rands (Numbers Only)
5.6.E. Approximate Completion Date
5.7.A. Country
5.7.B. Starting Date
5.7.C. Type of Contract
5.7.D. Total Contract Value (R) Rands (Numbers Only)
5.7.E. Approximate Completion Date
5.8.A. Country
5.8.B. Starting Date
5.8.C. Type of Contract
5.8.D. Total Contract Value (R) Rands (Numbers Only)
5.8.E. Approximate Completion Date
5.9.A. Country
5.9.B. Starting Date
5.9.C. Type of Contract
5.9.D. Total Contract Value (R) Rands (Numbers Only)
5.9.E. Approximate Completion Date
5.10.A. Country
5.10.B. Starting Date
5.10.C. Type of Contract
5.10.D. Total Contract Value (R) Rands (Numbers Only)
5.10.E. Approximate Completion Date

6. Supervision of Construction

6.1. Proportion of work where Firm both designs and supervises the actual construction (%) Numbers Only
6.2. Proportion of work where firm provides technical supervision of construction from the design made by other Firms (%) Numbers Only

7. Applicable to Limited Companies only

7.1. Do your charges accord with the scales sanctioned by the Professional Body in the field in which you are engaged?
Yes
No
None
7.2. If No, on what basis do you charge for your services?

8. Public Liability Cover

8.1. Do you currently have an insurance policy providing this coverage which is in force?
Yes
No
None
8.1.A. If Yes what is the retroactive date:
8.1.B. Limit of Liability required
8.1.C. Deductible/First Amount Payable Numbers Only
8.2. Do you operate in or have premises in the USA or Canada?
Yes
No
None
8.3. Has the insured suffered any loss, damage, sickness or injury or incurred any liability in the last 12 months that has or could have given rise to a claim under a public liability policy whether or not insurance was in force?
Yes
No
None
8.4. Has the insured ever had any proposal or renewal for public liability declined or had cover cancelled by insurers?
Yes
No
None
8.5. Is the insured involved in the provision of any educational, after-care, sporting or recreational facilities or activities for minors (under the age of 18)?
Yes
No
None
8.6. Does the insured provide any healthcare or medical treatment of any kind?
Yes
No
None
Proceed to Last Step for Building Industry
I am ready to continue
Back Next Save Progress
Complete 66%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Insurance Intermediaries

Business Description

1. Please provide a detailed Business description

2. Approximate percentage of estimated gross income accruing from various activities. 

State Approximate Percentage. Total must equal 100%.

2.1. Fire/Motor/Accident Business Numbers Only
2.2. Foreign Business Numbers Only
2.3. Liability Business Numbers Only
2.4. Life and Pensions (Including Retirement annuity Business) Numbers Only
2.5. Mortgage broking in conjunction with Life and Pensions Broking Numbers Only
2.6. Mortgage broking in conjunction with Life and Pensions Broking/Agency Numbers Only
2.7. Multimarket Goods in Transit Business Numbers Only
2.8. Aviation Hull & Liability Business Numbers Only
2.8.A. Please provide full details
2.9. Marine Hull Business Numbers Only
2.9.A. Please provide full details
2.10. Reinsurance/Reassurance Business Numbers Only
2.10.A. Please provide full details
2.11. Other Activities Numbers Only
2.11.A. Please provide full details
3. Do you provide an offering in respect of Outsourced/External Funds?
Yes
No
None
3.1. If yes, what is the Rand value if Total Funds (local and foreign) under Management Numbers Only
3.2. If yes, confirm that the fees generated from the Advice/Intermediary Services in relation to foreign or international investment (including any Forex related investments) does not exceed more than 10% of the FSP’s Gross Fee Income?
Yes
No
None
4. Do you provide an offering in respect of Internal/Own Managed Funds?
Yes
No
None
4.1. If yes, what is the Rand value if Total Funds (local and foreign) under Management Numbers Only
4.2. If yes, confirm that the fees generated from the Advice/Intermediary Services in relation to foreign or international investment (including any Forex related investments) does not exceed more than 10% of the FSP’s Gross Fee Income?
Yes
No
None
5. Do you provide an offering for any foreign or international investments?
Yes
No
None
5.1. If yes, what is the Rand value if Total Funds (local and foreign) under Management Numbers Only

6. Long Term/Investment

6.1. Financial planning (Life, Retirement Annuities and Pension Funds).
Yes
No
None
6.2. Investment Advice (Discretionary and Non-Discretionary)
Yes
No
None
6.2.A. If yes, please confirm that the Financial Investment Advisor(s) holds a minimum of either a CFP or FPI and 3 years of experience. (please be advised that cover will not attach if the above is not met).

6.3. Asset/Fund Management. PLEASE COMPLETE ATTACHED ANNEXURE A – The Fund and Asset Management Questionnaire

6.4. Does the FSP carry out Hedge Fund activities?
Yes
No
None
6.4.A. If yes, what is the Rand value if Total Funds (local and foreign) under Management Numbers Only
6.4.B. For your Hedge Fund activities, do you accept client deposits?
Yes
No
None
6.5. Does the FSP carry out Discretionary Investment activities?
Yes
No
None
6.5.A. If yes, what is the Rand value if Total Funds (local and foreign) under Management Numbers Only
6.6. For your Discretionary Investment activities, do you accept client deposits?
Yes
No
None
7. Money Market - Do you have your own trading room/operation platform or App?
Yes
No
None

8. Forex Trader

8.1. Do you have your own trading room/operation platform or App?
Yes
No
None
8.2. Do you provide Stockbroking activities?
Yes
No
None
8.3. Funeral?
Yes
No
None
8.4. Medical Aid/Healthcare?
Yes
No
None
9. Other Activities - Non FSP Related. Please provide a full description on a separate sheet
Drag & Drop Files Here Browse Files

10. Wills, Testaments, Trustee/Executor of Estate Lates.

10.1. Do you provide administrative services in respect of Wills and Testaments?
Yes
No
None
10.2. Is the business (Principals/Partners/Directors of the Business) appointed as either the Trustee or Executor of Estate Lates? If yes, please ensure that the Trustee/Executor fees are included in the annual declared fee income.
Yes
No
None
10.3. Do you provide Pension Fund Trustee services?
Yes
No
None

Professional/Business Relationships

1. Please check relevant boxes if you are a member of any of the following Professional Associations?
SAFSIA
IBC
LUASA
ILPA
SAUMA
None
2. Please provide you FAIS Number

3. Please advise what subcategories you are accredited for:

3.1. FIA
Yes
No
None
3.1.A. Membership Number
3.2. FPI
Yes
No
None
3.2.A. Membership Number

Business Associations

Details of all Joint Broking Appointments held by Proposer

1.A. Client
1.B. Type of Portfolio
1.C. Joint Broker
1.D. Apportionment of Work/Fees
2.A. Client
2.B. Type of Portfolio
2.C. Joint Broker
2.D. Apportionment of Work/Fees

Acceptance/Claims Authority

1. Do you have any Binding Underwriting and/or Claims Settlement Authorities, otherwise than in terms of standard Agency Contracts?
Yes
No
None

Details Of Insurance

1. Are you at present of have you in the past been Insured?
Yes
No
None

If yes, please provide the following details:

1.1. Name of Insurers
1.2. Date cover expires/d:
1.3. Retroactive date
1.4. Limit of Liability
1.5. Current Premium Numbers only

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

Quotations Required

1. Limit any one period of insurance inclusive of costs and expenses (Rands) Numbers only

2. Do you require any of the following extensions?

2.1. Dishonesty of staff other than Principals/Directors
Yes
No
None
2.2. Pension Trustees
Yes
No
None
2.3. Mortgage Broking in connection with Life Assurance
Yes
No
None
2.4. Mortgage Broking
Yes
No
None
2.5. Additional Insureds
Yes
No
None
2.5.A. If Yes, please provide details
Proceed to Last Step for Insurance Intermediaries
I am ready to continue
Back Next Save Progress
Complete 72%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Estate Agents & Valuers

1. Details of Insurance

1.1. Are you at present of have you in the past been Insured?
Yes
No
None

If yes, please provide the following details:

1.1.A. Name of Insurers
1.1.B. Date cover expires/d:
1.1.C. Retroactive date
1.1.D. Limit of Liability
1.1.E. Current Premium Numbers only

1.2. For the type of Insurance now being proposed, has any Insurer ever:

1.2.A. Declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
1.2.B. Required an increased premium or imposed special terms?
Yes
No
None
1.3.C. Cancelled an Insurance?
Yes
No
None
2. Detailed Business Description
3. Does the Company employ any independent Surveyor/Architect NOT being a partner or Member of the Insured’s staff for who cover is required?
Yes
No
None

If yes, please provide full details

3.1.A. Name
3.1.B. Date Qualified
3.1.C. Qualifications
3.2.A. Name
3.2.B. Date Qualified
3.2.C. Qualifications
3.3.A. Name
3.3.B. Date Qualified
3.3.C. Qualifications
4. Is cover required for retired/deceased partners?
Yes
No
None
4.1. If yes, please provide full details
5. Is the Company a member of a Professional Association?
Yes
No
None
5.1. If yes, please provide full details
6. Does the Company undertake Valuations?
Yes
No
None
6.1. If yes, please provide full details
7. What system is in place to prevent time limits under the Rent Act and Landlord and Tenant Act?
8. Is there a system in place to ensure that the provisions in respect of (a) above followed members of staff? (e.g. how often does Senior Partners/Principals check that the system is being properly implemented?)
Yes
No
None
8.1. If yes, please provide full details
9. Is there a system in place to ensure that all provisions and requirements as stipulated by the Estate Agencies Affairs Board/SA Council for the Property Valuers Profession and/or any other Industry Regulator or legislation is adhered to?
Yes
No
None
9.1. If yes, please provide full details
10. Attach a copy of the Company’s current Fidelity Fund Certificate
Drag & Drop Files Here Browse Files
11. Has the Estate Agencies Affairs Board/SA Council for the Property Valuers Profession or any other Industry Regulator instituted any claims/penalties and/or disciplinary actions against the company and/or any Partners/Principals/Directors or Employees?
Yes
No
None
11.1. If yes, please provide full details
12. When was the Company’s last Audit done?
12.1. State the name of the Auditors
12.2. Were the Financial Statements Qualified by Auditors?
Yes
No
None
12.2.A. If yes, please provide full details
12.3. What measures has been or will be put in place to address the qualified issues?

13. Approximate percentage of estimated gross income accruing from various activities.

Total must equal 100%.

13.1. Estate Agency Numbers Only
13.2. Building Society Agency Numbers Only
13.3. Surveys Numbers Only
13.4. Valuations Numbers Only
13.5. Estate/Property Management Numbers Only
13.6. Sectional Title Administrators Numbers Only
13.7. Rent Collecting Numbers Only
13.8. Quantity Surveying Numbers Only
13.9. Auctioning Numbers Only
13.10. Architectural/Design/Planning Work Numbers Only
13.11. Loss Assessing and Adjusting Numbers Only
13.12. Insurance Broking without Binding Authority Numbers Only
13.13. Insurance Broking with Binding Authority to issue Cover Notes and/or Certificates or have claims settlement authorities on behalf of Insurers Numbers Only
13.14. Mortgage Broking Numbers Only
13.15. Project Managers )Full details to be attached) Numbers Only
13.16. Project Managers - upload full details
Drag & Drop Files Here Browse Files

14. Business conducted outside South Africa

14.1. Does the company do any business for clients in the U.S.A, Canada, Australia or any other countries/states governed by their laws?
Yes
No
None

If yes, please provide the following details:

14.1.A. What percentage of your fees are attributable to these activities? Numbers Only
14.1.B. Do you have physical offices in these areas?
Yes
No
None
14.1.B.i. If yes, under who’s Management and Control are these offices?
14.1.B.ii. If yes, is there any foreign shareholding in these offices and if so what percentage?
Yes
No
None
14.1.B.iii. If yes, do you give any advice relating to the Laws of these Countries?
Yes
No
None
14.1.B.iii. If Yes, please provide details
14.2. Does the company or any partner, Director, etc. own any assets in the U.S.A, Canada or Australia?
Yes
No
None
14.2.A. If yes, please provide full details
14.3. Does the company operate in any other countries outside of RSA?
Yes
No
None
14.3.A. If yes, please provide full details
Proceed to Last Step for Estate Agents
I am ready to continue
Back Next Save Progress
Complete 77%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Miscellaneous

1. Please provide a detailed business description
2. Do you or your company do any business for your clients in the U.S.A, Canada or any other countries/states governed by their laws?
Yes
No
None
2.1. If yes, please provide full details
3. Is the company or any of the Directors/Partners connected or associated (financially or otherwise) to any other firm, company or organisation?
Yes
No
None
3.1. If yes, please provide full details
Proceed to Last Step for Miscellaneous
I am ready to continue
Back Next Save Progress
Complete 83%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Accountants & Auditors

1. Details of Insurance

1.1. Are you at present of have you in the past been Insured?
Yes
No
None

If yes, please provide the following details:

1.1.A. Name of Insurers
1.1.B. Date cover expires/d:
1.1.C. Retroactive date
1.1.D. Limit of Liability
1.1.E. Current Premium Numbers only

1.2. For the type of Insurance now being proposed, has any Insurer ever:

1.2.A. Declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
1.2.B. Required an increased premium or imposed special terms?
Yes
No
None
1.3.C. Cancelled an Insurance?
Yes
No
None

2. Approximate percentage of estimated gross income accruing from various activities.

Total must equal 100%.

2.1. Auditing Fees Numbers Only
2.2. Accounting and Secretarial Numbers Only
2.3. Taxation Only Numbers Only
2.4. Management Consultancy Numbers Only
2.5. Other Consultancy (Please provide full details) Numbers Only
2.5.A. Other Consultancy Details
2.6. Share Registration Numbers Only
2.7. Executors and Trusteeship Numbers Only
2.8. Voluntary Liquidations Numbers Only
2.9. Insolvencies, Compulsory Liquidations, Judicial Management & Receiverships Numbers Only
2.10. Other Activities (Please provide full details) Numbers Only
2.10.A. Other Activities Details

3. Please provide the following details where services are rendered through other companies (if any).

3.1. Details of Companies

3.1.A. Company
3.1.A. Directors
3.1.A. Activities
3.1.A. Annual Income of the Company Numbers Only
3.1.A. Annual Income Accruing to the Insured Numbers Only
3.1.B. Company
3.1.B. Directors
3.1.B. Activities
3.1.B. Annual Income of the Company Numbers Only
3.1.B. Annual Income Accruing to the Insured Numbers Only
3.1.C. Company
3.1.C. Directors
3.1.C. Activities
3.1.C. Annual Income of the Company Numbers Only
3.1.C. Annual Income Accruing to the Insured Numbers Only
3.2. Ownership: Details of any financial interest in any Company named above, of any person other than a nominee of the partners of the insured.

3.3. Management and Control

3.3.1. Name of Partner responsible for activities of each company.
3.3.2. Does any Company employ staff directly?
Yes
No
None
3.3.3. Any functions of the Company exercised exclusively by partners/employees of the Insured?

3.3.4. Clientele and contractual relationships.

Does any Company:
offer its services (directly or through the Insured) to persons who are NOT clients of the Insured?
enter into direct contractual relationships with clients?
None

4. Please provide the following details in respect of business conducted outside South Africa.

4.1. 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
None
4.1.A. If Yes, how many visits have been made to these countries/states during the last 12 months?
4.2. How many working days have been spent in there in the last 12 months?

5. Inter partnership arrangements

5.1. Do you have any inter-partnership arrangements with other Accountants, or firms of Accountants? 
Yes
No
None
5.1.A. If yes, do these firms carry out work in the name of your firm or vice-versa? 
Yes
No
None
5.2. Do they have a similar professional indemnity policy... 
Yes
No
None
5.2.A. ...and for what Limit of Indemnity
5.3. 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.
Drag & Drop Files Here Browse Files
Proceed to Last Step for Accountants
I am ready to continue
Back Next Save Progress
Complete 88%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 Declaration

Computer Industry

Staff Complement

1. How many staff are employed by the Firm? Numbers Only

2. State the total number of staff in the following designations:

2.1. Principals Numbers Only
2.2. Software Design/Systems Analysts Numbers Only
2.3. Quality Assurance Numbers Only
2.4. Computer Equipment Operators/Data Handling Staff Numbers Only
2.5. Sales of Hardware/Software Numbers Only
2.6. All Other Numbers Only
2.7. Total Numbers Only
3. How many staff, other than Principals, have the authority to quote prices for services performed by the Firm? Numbers Only

Business Associations

1. Is the Firm or any Principal connected or associated (financially or otherwise) with any other Firm or Organisation for whom work may be undertaken for, or in connection with the proposer?
Yes
No
None
1.1. If yes, please give full details:
2. Do you have access to standby equipment following breakdown or failure or damage to computers or ancillary equipment used by the Firm?
Yes
No
None
2.1. If yes, please state what arrangements are made:

3. Do you ensure that duplicate computer systems records are:

3.1. Maintained by yourselves or your clients?
Yes
No
None
3.2. Kept separately from the original records?
Yes
No
None
3.3. If yes, please state what arrangements are made:
4. Give a brief description of typical projects or assignments undertaken by the Firm during the past three (3) years.
5. Do you design Computer Software packages?
Yes
No
None
5.1. If yes, a copy of the contract documents must be uploaded with this form.
Drag & Drop Files Here Browse Files
6. Do you install Computer Hardware on behalf of another firm as a contractor.
Yes
No
None
6.1. If yes, a copy of the contract documents must be uploaded with this form.
Drag & Drop Files Here Browse Files
7. If (6) above is not applicable, then do you design, manufacture and assemble the units yourselves?
Yes
No
None
7.1. If yes, please give details:

Fee Income

1. Please state Total Gross Income for last 12 months Numbers Only

Split between the following Disciplines

1.1.A. General Consultancy

1.1.B. Local Numbers Only
1.1.C. Foreign Numbers Only

1.2.A. Systems and/or programme design

1.2.B. Local Numbers Only
1.2.C. Foreign Numbers Only

1.3.A. Data Processing and/or Communications

1.3.B. Local Numbers Only
1.3.C. Foreign Numbers Only

1.4.A. Sale of Software packages where programme code is modified for a specific client

1.4.B. Local Numbers Only
1.4.C. Foreign Numbers Only

1.5.A. Sales of Hardware

1.5.B. Local Numbers Only
1.5.C. Foreign Numbers Only

1.6.A. Sales of Software packages which have the same Programme code

1.6.B. Local Numbers Only
1.6.C. Foreign Numbers Only

1.7.A. Other

1.7.D. Please specify principal categories
1.7.B. Local Numbers Only
1.7.C. Foreign Numbers Only
1.8. Is any of this work subject to the legal jurisdiction of foreign courts?
Yes
No
None
1.8.A. If yes, which countries:

2. Please split your income for the last 12 months between South Africa and Overseas (Specify Country)

2.1.A. Government

2.1.B. South Africa % Numbers Only
2.1.C. Overseas % Numbers Only
2.1.D. Country

2.2.A. Finance Houses

2.2.B. South Africa % Numbers Only
2.2.C. Overseas % Numbers Only
2.2.D. Country

2.3.A. Commercial Firms

2.3.B. South Africa % Numbers Only
2.3.C. Overseas % Numbers Only
2.3.D. Country

2.4.A. Industrial Firms

2.4.B. South Africa % Numbers Only
2.4.C. Overseas % Numbers Only
2.4.D. Country

2.5.A. Other Work

2.5.B. South Africa % Numbers Only
2.5.C. Overseas % Numbers Only
2.5.D. Country
3. Estimated income for next 12 months: Numbers Only
3.1. Are any changes expected in the next 12 months?
Yes
No
None
3.1.A. If yes, please give details:
4. Have you made, or will you make any commitments as to sales volume or sales value with any of your suppliers?
Yes
No
None
4.1. If yes, please specify the amount as a proportion of your income for the past 12 months (%) Numbers Only
5. What proportion of Gross Income under (1) above is derived from the application of computers to industrial processes or engineering or architectural design (other than accountancy, production or stock control)? (%) Numbers Only
5.1. Please give brief details of such work:
Back Next Save Progress
Complete 94%
1 Details of Proposed Insured 2 Professional Claims History 3 Fee Income 4 Profession Specific Questions 5 Attorneys 6 Attorneys - Misappropriation of Trust Funds Cover Intro 7 Attorneys - Misappropriation of Trust Funds Cover 8 Attorneys - Commercial Crime Intro 9 Attorneys - Commercial Crime 10 Attorneys - Third Party Impersonation Fraud Cover Intro 11 Attorneys - Third Party Impersonation Fraud Cover 12 Building Industry 13 Insurance Intermediaries 14 Estate Agents 15 Miscellaneous 16 Accountants and Auditors 17 Computer Industry 18 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
Back Next Save Progress