PUBLIC AND/OR PRODUCTS LIABILITY

 

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Details of Proposed Insured

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
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2. Detailed Business Description

Please provide a detailed business description.  If engaged in multiple disciplines, please provide a percentage split - total must add up to 100%.

3. Claims Experience

3.1. 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 (including but not limited to Single Projects)?
Yes
No
None
3.1.1. If yes, please provide full details:
3.2. 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, or any other Policy for the same type of cover (including but not limited to Single Projects), that may result in any claims or any possible claims being made against them?
Yes
No
None
3.2.1. If yes, please provide full details:

4. Details of Insurance

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

If yes, please provide the following details:

4.1.1. Name of Insurers
4.1.2. Date cover expires(d)
4.1.3. Retroactive date
4.1.4. Current premium Numbers only

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

4.2.1. declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
4.2.2. required an increased premium or imposed special terms?
Yes
No
None
4.2.3. cancelled an insurance?
Yes
No
None
4.2. If yes, please provide full details:
4.3. Do you require cover in respect of any liability incurred but not discovered prior to the effecting of this insurance at a single premium to be negotiated?
Yes
No
None

5. Staff Compliment

Total Number of:

5.1. Partners/Principals/Directors Numbers Only
5.3. All Other Staff Numbers Only
5.2. Professional Assistants/Accounts Executives Numbers Only
5.4. Total Numbers Only
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6. Products

6.1. Do you require Product Liability cover?
Yes
No
None
6.1.A. Please provide list of products (major categories)
6.1.B. Identify any products above which involve design (by Proposers own staff)
6.1.C. Identify any products above which involve design (by outside parties)
6.2. Are staff involved academically qualified?
Yes
No
None
6.2.A. If Yes, please provide details of qualifications and years of experience
6.2.B. If No, please provide details and years of experience
6.3. In respect of products or services obtained from outside parties, are full rights of recourse retained?
Yes
No
None
6.3.A. If No, please provide details regarding degree of recourse which is waived
6.4. Overseas markets to which products are exported (Nature of Product | Turnover | Country to which exported)
6.4. Are any assets held outside the Republic of South Africa?
Yes
No
None
6.4.A. If yes, please provide brief details
6.5. Please provide details of the anticipated failure rate of each product i.e. after it has been sold or supplied to customers and where it is then returned by customers, for replacement, or where it is rejected by customers or end users. N.B. This question should be answered, whether products guarantee insurance is being proposed for or not.
6.6. Please attach standard trading conditions and any other literature which will assist Insurers in obtaining an understanding of the risk.
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6.7. Please provide any other information which may be relevant to Insurers understanding of the insurance being proposed for e.g. but not limited to:

  • use of explosives
  • prototype products
  • potentially hazardous waste products
  • potentially hazardous by-products
  • potential for spreading of fire
  • known problems with similar products by competitors
  • any other unusual or significant liability risk factors
6.7.A. Type ifnromation here:
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7. Fee Income

As at the company’s financial year end.

Please give the audited fees for the past 5 years:

2019 Fees (Rand) Numbers in Rands
2020 Fees (Rand) Numbers in Rands
2021 Fees (Rand) Numbers in Rands
2022 Fees (Rand) Numbers in Rands
2023 Fees (Rand) Numbers in Rands
Estimate for the next 12 months (Rand) Numbers in Rands

8. Quotations Required

Specific nature of cover being proposed for and indemnity limit.

8.1. Public Liability Indemnity Limit (Rand). Unlimited in the year. Numbers Only
8.2. Products Liability Indemnity Limit excluding inefficacy (Rand). In aggregate in the year. Numbers Only
8.3. Products Liability Indemnity Limit including inefficacy (Rand). In aggregate in the year. Numbers Only
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I/We the undersigned duly authorised person(s) declare that:

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