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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Details of the Proposed Insured

Insured/Name of Firm (Your legal entity – please be accurate – to be used on your policy contract) *
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 Firm:

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/Key Individuals (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
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Complete 4%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Professional Claims History

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:
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Complete 8%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Fee Income

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
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Complete 12%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Profession Specific Questions

Please select your Profession before continuing *
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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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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.
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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
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Complete 20%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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)
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Complete 25%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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
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Complete 29%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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)
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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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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
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Complete 37%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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 41%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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.
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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.

Proceed to Last Step for Attorneys*
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Complete 45%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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
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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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Insurance Intermediaries

General

1. FSP Number
2. Are you a Juristic Representative of an FSP?
Yes
No
None
2.1. If Yes, please provide the full FSP Name and Number.
3. Subsidiary Firms and Offices (Provide Name, City and Country).
4. Please provide a detailed Business Description. Please be accurate - your policy contract is based on this information.

Percentage Breakdown of Current Business Activities

1. Short Term

 1.1. Agriculture and Farming
Yes
No
None
1.1. Percentage % of GFI Numbers Only
1.1.1. What % of the total revenue is generated from Crop Insurance? Numbers Only
1.1.2. What is the insured value of the largest crop insurance account? Numbers Only
1.2. Bankers Blanket Bond (BBB)
Yes
No
None
1.2. Percentage % of GFI Numbers Only
1.3. Commercial Crime
Yes
No
None
1.3. Percentage % of GFI Numbers Only
1.4. Commercial/Multiperil (Multimark)
Yes
No
None
1.4. Percentage % of GFI Numbers Only
1.5. Construction and Engineering All Risk/Single Projects
Yes
No
None
1.5. Percentage % of GFI Numbers Only
1.6. Corporate, Assets All Risks
Yes
No
None
1.6. Percentage % of GFI Numbers Only
1.7. Directors & Officers/Management Liability
Yes
No
None
1.7. Percentage % of GFI Numbers Only
1.8. F & I Risks - Applicable to Motor Dealerships (Scratch & Dent, Warranty Policies, Credit shortfall, Credit Life etc.)
Yes
No
None
1.8. Percentage % of GFI Numbers Only
1.9. Funeral Cover
Yes
No
None
1.9. Percentage % of GFI Numbers Only
1.10. GAP Cover
Yes
No
None
1.10. Percentage % of GFI Numbers Only
1.11. Guarantees, Court and Bonds
Yes
No
None
1.11. Percentage % of GFI Numbers Only
1.12. Personal Lines
Yes
No
None
1.12. Percentage % of GFI Numbers Only
1.13. Professional Indemnity (PI)/Liability
Yes
No
None
1.13. Percentage % of GFI Numbers Only
1.14. Aviation (If Yes, please fill in Annexure C after this section)
Yes
No
None
1.14. Percentage % of GFI Numbers Only
1.15. Marine (If Yes, please fill in Annexure C after this section)
Yes
No
None
1.14. Percentage % of GFI Numbers Only

2. Long Term

2.1. Company Pension and Healthcare Consulting and Advisory
Yes
No
None
2.1. Percentage % of GFI Numbers Only
2.2. Employee Risk Benefits
Yes
No
None
2.2. Percentage % of GFI Numbers Only
2.3. Financial Planning, Investment Consulting and Advice
Yes
No
None
2.3. Percentage % of GFI Numbers Only
2.4. Incidental Tax Advice
Yes
No
None
2.4. Percentage % of GFI Numbers Only
2.5. Health Products (Hospital Plan)
Yes
No
None
2.5. Percentage % of GFI Numbers Only
2.6. Life Products
Yes
No
None
2.6. Percentage % of GFI Numbers Only
2.7. Medical Aid Products
Yes
No
None
2.7. Percentage % of GFI Numbers Only
2.8. Property Syndication
Yes
No
None
2.8. Percentage % of GFI Numbers Only
2.9. Retirement and Health Administration, Actuarial
Yes
No
None
2.9. Percentage % of GFI Numbers Only
2.10. Fund & Asset Management (If Yes, please fill in Annexure A after this section)
Yes
No
None
2.10. Percentage % of GFI Numbers Only

3. Reinsurance and Alternative (ART)

3.1. Total % Numbers Only
3.2. Are you involved in the following activities Deceased Estates – Executrix, Wills and Testaments, Inter-vivos & Testamentary Trust?
Yes
No
None

Your Work Outside the Republic of South Africa

1. Do you undertake any work in territories outside South Africa?
Yes
No
None

1. If Yes, please advise:

1.1. Country
1.1. Fee Income (R) Numbers Only
1.2. Country
1.2. Fee Income (R) Numbers Only
1.3. Country
1.3. Fee Income (R) Numbers Only

Sanctions

No Indemnity may be granted by Insurers in respect of any services provided by You in a SANCTION TERRITORY or to a SANCTIONED PERSON as listed by the United Nations, the United Kingdom, or United States of America.

Joint Broker Appointments

Declare fees you earn in the financial declaration in order to be covered for the extent of liability devolving upon you arising out of the services you perform and provided.


1. Are you involved in any contract where you agreed with others to jointly provide the services as detailed under "Detailed Business Description" and "Percentage Breakdown of Current Business Activities".
Yes
No
None

Details of all Joint Broking Appointments you hold

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

Outsource Agreements

1. Do you have such outsource agreements granted to you by any Insurer authorizing you to perform binder or any other functions on behalf of the Insurer? (If Yes, please fill in Annexure B after this section)
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

Financial Declaration

Your Gross Income - Please provide a copy of the latest verified financials below.
This must be an accurate declaration in accordance with your financial statement.  Failure to provide an accurate declaration may prejudice your cover.

1. Commission/Brokerage Income

1.1. Last Finanical Year (R) Numbers only
1.2. Present Financial Year (R) Numbers only
1.3. Esimtated Financial Year (R) Numbers only

2. Binder and Outsource Fees

2.1. Last Financial Year (R) Numbers only
2.2. Present Financial Year (R) Numbers only
2.3. Estimated Financial Year (R) Numbers only

3. Broker Policy Charges and Fees 

3.1. Last Financial Year (R) Numbers only
3.2. Present Financial Year (R) Numbers only
3.3. Estimated Financial Year (R) Numbers only

4. Other Additional Income 

4.1. Last Financial Year (R) Numbers only
4.2. Present Financial Year (R) Numbers only
4.3. Estimated Financial Year (R) Numbers only

5. TOTAL Financial Year End

5.1. Last Financial Year (R) Numbers only
5.2. Present Financial Year (R) Numbers only
5.3. Estimated Financial Year (R) Numbers only
Please provide a copy of the latest verified financials.
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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

Risk Management

The purpose of this section is to obtain confirmation of your risk management protocol but also to provide you positive feedback regarding important business management to prevent claims against you and to Protect Your Reputation.

Basic Risk Management means a record, implementation and continuous monitoring of proper internal procedures to mitigate risk. We want to know if you have implemented the following:

1. General Risk Management

1.1. Do you keep a record of all communication to Your Customers about identifying and confirming uninsured risks and exposures which includes Your Customer’s decision not to insure such risks and exposures (Applicable to short-term brokers)?
Yes
No
None
1.2. Do you keep a record of all communication about Your Customer’s needs and exposures including instructions from You to any Insurer?
Yes
No
None
1.3. Record of Advice - Do you record in writing or electronically any renewal discussion advice provided and communicated to Your Customer?
Yes
No
None
1.4. Do you have a written mandate in place for each client?
Yes
No
None
1.5. Do You do a Needs Analysis with each client?
Yes
No
None
1.6. Do You have a formal renewal process with dated reminders to Your Customer?
Yes
No
None

2. Cyber Third-Party Liability

2.1. Do You establish the identity, authenticity and authority of any person sending you instructions?
Yes
No
None
2.2. Do You confirm that the banking details from or to which funds are transferred are authentic and belong to the sending or receiving party?
Yes
No
None
2.3. Do You ensure an absolute non-acceptance of telephonic instructions to alter banking, personal, email, telephone or similar detail?
Yes
No
None
2.4. Do You verify that any email instructions match and are identical to the applicable records you hold?
Yes
No
None

2.5. Do you protect your computer, data and electronic systems with:

2.5.1. Up to date security and security patches?
Yes
No
None
2.5.2. Data backup protocols in separate secure locations?
Yes
No
None
2.5.3. Authentication processes to allow only trusted connections?
Yes
No
None
2.5.4. External firewalls to prevent external access?
Yes
No
None
2.5.5. Password and access policy to maintain security and prevent unauthorized access?
Yes
No
None

3. Fidelity Own Money/Third-Party Property and Money

3.1. Are criminal and credit checks performed on new Employees during the policy period?
Yes
No
None
3.2. Do you have an enforced leave policy in place with a minimum of five consecutive days in a calendar year?
Yes
No
None
3.2. Do you have an enforced leave policy in place with a minimum of five consecutive days in a calendar year?
Yes
No
None
3.3. Do you have a segregation of duties and dual authority with regards to processing, loading, releasing and authorizing payments and electronic funds transfers?
Yes
No
None
3.4. Do you have a policy in place to ensure that payee’s and/or beneficiaries’ details on electronic funds transfers are verified with the actual account holder before making a payment?
Yes
No
None
3.5. Are procedures in place to control the creation of new payees and/or beneficiaries and changes to existing payees and/or beneficiaries including the telephonic confirmation of bank details and recording thereof?
Yes
No
None
3.6. Are all bank tokens and bank access cancelled on the termination of an employee’s employment within the company?
Yes
No
None

Material Information

This form has prompted you to provide certain information. There may be additional material information which is specific to your business profile, and which has not been provide above.

 

This material information should be declared to us separately.

 

Material information means any information which might influence our judgment in accepting your risk. If you wilfully suppress or conceal or fail to disclose material information this could affect indemnity. Disclosing information will also allow us to assess your risk positively which could lead to significantly improved policy terms.

 

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Complete 54%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration
Have you been requested to fill out Annexure A?*
Yes
No
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Complete 58%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Insurance Intermediary Annexure A - CAT II - The Fund and Asset Management

Additional Questions for Financial Services Providers


This set of questions are intended to bring definition and clarity to the scope of activity undertaken. Your input in clarifying your activity will significantly enhance the understanding of your exposures.  In providing your answers additional information may be pertinent. This information should be added as appropriate.


1. Funds Transfer Instructions & Authentication

1.1. Do you make use of a linked investment service provider (LISP)?
Yes
No
None
1.1. If Yes, please list them:
1.2. Does the investor deposit funds directly to the LISP?
Yes
No
None
1.2. If No, please explain:
1.3. Are withdrawals paid directly by the LISP to the investor?
Yes
No
None
1.3. If No, please explain:
1.4. How are investors withdrawal instructions (fax, email or otherwise) recorded and authenticated?

2. Internal Controls

2.1. Do you require all Directors and Employees to declare their outside business interests and specify relationships which could lead to possible conflicts of interest?
Yes
No
None
2.2. Are the duties of each Employee arranged so that no one Employee is permitted to control any transaction from commencement to completion?
Yes
No
None
2.2. If No, please explain:

3. Investment Statements

3.1. Do your investors receive automated investment statements via the LISP?
Yes
No
None
3.1. If No, please explain what system/process is used to create the investment statements and what checks and balances are in place to ensure the integrity of the information being disseminated to clients?
3.2. How often are investment statements issued to investors?
Daily
Monthly
Quarterly
Bi-Annually
Annually
None
3.3 Who submits the investment statements to the investors, if not via the LISP?

4. Asset/Fund Management/Administration

4.1. Do you have bespoke or white labelled (broker fund) investment products?
Yes
No
None
4.1. If Yes, please provide a full description of the product and include confirmation of the underlying assets.
4.2. Who manages the investment in these products?
If you do, please confirm how you do the analysis and determine the blend of the fund (in the box below)
If you do not, please confirm who does this work and specifically how you contract with, monitor or manage the performance of the relevant party (in the box below).
None
4.2. Details:

4.3. Please provide the following Fund values:

Total Third-Party Funds Under Management

4.3.1. Discretionary Management

4.3.1. As at last financial year end (R)
4.3.1. As at current/last date of interim report (R)

4.3.2. Non-Discretionary Management

4.3.2. As at last financial year end (R)
4.3.2. As at current/last date of interim report (R)

4.3.3. Administration

4.3.3. As at last financial year end (R)
4.3.3. As at current/last date of interim report (R)

4.4. Names of all Fund Managers, length of service, specific responsibilities and person qualifications:

4.4.1. Name
4.4.1. Length of Service
4.4.1. Responsibilities
4.4.1. Qualifications
4.4.2. Name
4.4.2. Length of Service
4.4.2. Responsibilities
4.4.2. Qualifications
4.4.3. Name
4.4.3. Length of Service
4.4.3. Responsibilities
4.4.3. Qualifications
4.4.4. Name
4.4.4. Length of Service
4.4.4. Responsibilities
4.4.4. Qualifications

4.5. Complete/Provide a Fact Sheet for each Fund

4.5.1. Fund Name (Own Managed Fund)

4.5.1. Fund Size (R)

4.5.2. Fund Name (Own Managed Fund)

4.5.2. Fund Size (R)

4.5.3. Fund Name (Own Managed Fund)

4.5.3. Fund Size (R)

4.5.4. Fund Name (Own Managed Fund)

4.5.4. Fund Size (R)
4.5.5. Upload Fact Sheets
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5. Additional Information
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Complete 62%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration
Have you been requested to fill out Annexure B?*
Yes
No
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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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Insurance Intermediary Annexure B - Supplementary Questionnaire

Outsource agreement supplementary questions.

 

This set of questions are intended to bring definition and clarity to the scope of activity undertaken. Your input in clarifying your activity will significantly enhance the understanding of your exposures.  In providing your answers additional information may be pertinent. This information should be added as appropriate.

1. List the Insurer.
2. List the classes of business.

3. Is the Outsource Agreements in writing and signed by:

3.1. The authorised/mandated signatories on behalf of your brokerage?
Yes
No
None
3.2. The authorised/mandated signatories on behalf of the relevant Insurer?
Yes
No
None
3.3. If either of the above has been answered No, please provide FULL and DETAILED reasons:
4. Are there contractual requirements for each Outsource Agreement set out in accordance with Prudential Standard GO15?
Yes
No
None
4.1. If No, please provide DETAILED reasons:
5. What is the maximum limit authorised under this Outsource Agreement?
6. Have you contractually limited your liability to the subscribing Insurer?
Yes
No
None
6.1. If Yes, please provide the total maximum Rand Value.
7. Do you delegate any activities under this Outsource Agreement to any other party?
Yes
No
None
7.1. If Yes, please provide FULL details:
8. Do you have claims settlement authority for this Insurer?
Yes
No
None
8.1. If Yes, please provide the maximum settlement limit.
9. Do you place reinsurance in respect of this Outsource Agreement?
Yes
No
None
10. Have there been ANY claims/notifications/circumstances notified in relation to this Outsource Agreement?
Yes
No
None
10.1. If Yes, please provide FULL details:
11. Have there been any material changes in respect of this Outsource Agreement in the past twelve months?
Yes
No
None
11.1. If Yes, please provide FULL details:
12. Are there any material changes in respect of this Outsource Agreement planned in the next twelve months?
Yes
No
None
12.1. If Yes, please provide details:
13. Do you undertake any work in respect of this Outsource Agreement outside of South Africa?
Yes
No
None
13.1. If Yes, please list the countries:
14. Is this Outsource Agreement?
Non-discretionary with no deviation from the Outsource Agreement in respect of the type of risk, the rates, the period of insurance or the policy wording applicable, as specified in the Outsource Agreement.
Non-discretionary with no deviation from the Outsource Agreement in respect of the type of risk, the period of insurance or policy wording applicable but with a limited amount of deviation permissible to the extent of discounts or loadings specifically outlined within the Outsource Agreement.
Non-discretionary with no deviation from the Outsource Agreement in respect of the type of risk and wording applicable but deviation permissible in respect of the period of Insurance of non-specified discounts or loadings.
Discretionary Outsource Agreement with no limits in respect of the type of risk, ratings, wording, or the period of Insurance.
None
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Complete 70%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration
Have you been requested to fill out Annexure C?*
Yes
No
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Complete 75%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 Declaration

Insurance Intermediary Annexure C - Marine & Aviation Supplementary Questions

This set of questions are intended to bring definition and clarity to the scope of activity undertaken. Your input in clarifying your activity will significantly enhance the understanding of your exposures. In providing your answers additional information may be pertinent. This information should be added as appropriate.

1. Marine

1.1. Number of years’ experience in this field.
1.2. Maximum Value/Sum Insurance any one policy on your books.
1.3. Average number of policies written annually.

1.4. Please provide a percentage split for the activities below.

Total must equal 100%.

1.4.1. Small/Light Craft
1.4.2. Goods in Transit (In SA Only)
1.4.3. Marine Cargo (SA Only)
1.4.4. Stock Throughput
1.4.5. Commercial Hull
1.4.6. Other (Please specify below)
1.4.6. Other Details:

2. Aviation

2.1. Number of years’ experience in this field.
2.2.  Maximum Value/Sum Insured any one policy in your books.
2.3. Average number of policies written annually.

2.4. Please provide a percentage split for the activities below.

Total must equal 100%.

2.4.1. Private Aircraft (Light Sport Aircraft/Small Experimental Kit Aircraft/Microlights/Gyrocopters).
2.4.2. Commercial/Corporate Aircraft/Microjets/Cargo/Charter)
2.4.3. Helicopters (Private Operators/Lite Aircraft)
2.4.4. Drone
2.4.5. Other (Please specify below)
2.4.5. Other Details:
I have completed all required Annexures for Insurance Intermediaries
I am ready to continue
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Complete 79%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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
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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
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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
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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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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
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Complete 87%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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.
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Complete 91%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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.
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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.
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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:
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Complete 95%
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 II Annexure A Select 15 II Annexure A - CAT II - The Fund and Asset Management 16 II Annexure B Select 17 II Annexure B - Supplementary 18 II Annexure C Select 19 II Annexure C - Marine & Aviation Supplementary 20 Estate Agents 21 Miscellaneous 22 Accountants and Auditors 23 Computer Industry 24 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 *
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