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PROFESSIONAL INDEMNITY PROPOSAL FORM FOR UNDERWRITING AGENTS, POOL

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					PROFESSIONAL INDEMNITY PROPOSAL FORM FOR UNDERWRITING AGENTS, POOL MANAGERS AND HOLDERS OF BINDING AUTHORITIES

A. B. C.

Answer all questions leaving no blank spaces. If you have insufficient space to complete any of your answers, continue on your headed paper. It is the intention of Underwriters that any Contract of Insurance with the Proposer shall be based upon the answers and information provided in this Proposal Form and any other additional information provided by the Proposer. If a quotation is offered it will be the intention of Underwriters to offer coverage only in respect of those entities named in answer to Question 1.

D.

Completion of this form does not bind the Proposer or Insurer to complete the insurance transaction. ______________________________________________________________________________

A.

PARTICULARS OF PROPOSER 1. State the name and address of the Proposer, listing all subsidiaries for which cover is requested, indicating the location, date of establishment and principal activity of each company. Proposer: ________________________________________________________ Head Office Physical Address: ________________________________________________________ ________________________________________________________ ________________________________________________________ Postal Code: _____________________________________________

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Postal Address: _______________________________________________________ _______________________________________________________ _______________________________________________________ Postal Code: ____________________________________________

Name of Subsidiary _______________ _______________ 2.

Location _______________ _______________

Date Established ____________ ____________

Principal Activity _____________ _____________

Company Registration No. _____________________________

3.

Company VAT Registration No. _____________________________

4.

Date of Commencement of Underwriting Activities: _____________________________

5.

Is the Proposer registered in terms of the Financial Advisory and Internediary Services Act of 2002? YES If Yes, please advise FSP No. __________________ NO

B.

FINANCIAL INFORMATION 1. Please state: Year End 2005 Year End 2006 Year End 2007 Year End 2008 (Est)

a) Gross Written Premium b) Total Commission c) Consulting Fees or other charges (Profit Commission) TOTAL:

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2.

Please state percentage of income derived from: Year End 2005 Year End 2006 Year End 2007 Year End 2008 (Est)

a) UK b) USA/ Canada c) Europe d) Elsewhere

3.

Please state Classes of Business together with Percentage of Total Income: Year End 2006 Year End 2007 Year End 2008 (Est)

a) Non-Marine Facultative Direct – Purely Professional Indemnity and Specialised Liability Risks b) Non-Marine Treaty c) London Market Excess d) Marine Facultative and Direct e) Marine Treaty f) Motor g) Aviation h) Life and Pensions i) Mortgage Broking j) Other (Please specify) ______________________________

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C.

STAFF/ QUALIFICATIONS 1. Please provide the following details: Qualifications Year Obtained How long a Director/ Partner/ Principal of the Firm or Company

Names of all Directors/ Partners/ Principals

2.

Please provide total number of: a) b) c) d) e) f) Partners/ Directors/ Principals Qualified Staff Other Staff (excl admin) Administrative Staff Contract Hired Staff Total number of Staff _____________ _____________ _____________ _____________ _____________ _____________

D.

OTHER ACTIVITIES 1. Is any Director or Partner, or, (so far as the Proposer is aware)any Shareholder also a Director, Partner or Shareholder in: a) b) c) Any Insurance Broker or Agent Any other Underwriting Agency, Pool Manager or Holder of Binding Authority Any of the Insurers subscribing to the Agency, Pool or Authority. __________________ __________________ __________________

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If Yes, please provide details: ______________________________________________________________

2.

Does any Director/ Partner or Employee of the Proposer also act as an Insurance Broker or Agent to the Proposer? YES If yes, please provide details. _______________________________________________________________ NO

3.

Is the Proposer responsible for the: a) Investment of underwriting funds? YES b) Reinsurance programme protecting the underwriting account? YES NO NO

4.

Does the Proposer undertake any other duties (e.g. loss adadjusting) for which cover is required? YES NO

5.

Does the Proposer participate in “fronting” arrangements? YES NO

6.

Please complete the Supplementary Questionnaire and enclose copies of the Underwriting Accounts for the last financial year and the agreement(s) providing Underwriting Authority, Binding Authority, or Pool Authority.

E.

CLAIMS EXPERIENCE 1. Have any claims ever been made against the Proposer, their predecessors in business or any of the present Partners or Directors, or to the knowledge of the Proposer, against any past Partners or Directors, for the type of cover for which you are now applying? YES NO

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If yes, please provide full details: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 2. Is any Director or Partner aware, after enquiry, of any circumstances which may result in any claim being made against the Proposer, his predecessors in business or any of the present or past Partners or Directors? YES NO If yes, please provide full details: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

F.

INSURANCE HISTORY 1. Are you in the present of have you in the past been Insured? YES If Yes, please state: a) b) c) d) e) 2. Name of Insurers Indemnity Limit Deductible Date of expiry of coverage Retroactive Date ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ NO

For the type of Insurance now being Proposed, has any Insurer ever: a) b) Declined Proposal or renewal? YES NO

Required an increased premium or imposed special terms? YES Cancelled the Insurance? YES

NO NO

c)

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If any answer is Yes, please provide full details. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

G.

REQUIRED COVER

1.

Please state the amount of indemnity required. _____________________________________________________________

2.

Please state the deductible required. _____________________________________________________________

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DECLARATION

We declare that the statements and particulars in this Proposal Form are true to the best of our knowledge and belief and that we have not misstated, suppressed or omitted any material facts. We agree that this Proposal Form together with any other information supplied by us shall form the basis of any contract of Insurance effected thereon and shall be incorporated therein. We undertake to inform Insurers of any material alteration of these facts whether occurring before or after completion of the contract of Insurance. Signing this Proposal Form does not bind the Proposer to complete this Insurance. We acknowledge that if this proposal is accepted, the contract of insurance will be subject to the terms and conditions as set out in the policy wording as issued or as otherwise specifically varied in writing by Phoenix Underwriting Managers (Pty) Ltd. DATED THIS __________________________ DAY OF ______________________ 20_____

FOR AND ON BEHALF OF: ___________________________________________________ SIGNED BY: ___________________________________ Managing Director ___________________________________ Chairman, Board of Directors

PLEASE NOTE:

This Proposal Form should be completed by YOU and signed by YOU. If the Proposal Form has been completed by your BROKER, review the Proposal Form before signing it. DO NOT sign a BLANK Proposal Form.

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SUPPLEMENTARY QUESTIONNAIRE (REFER TO QUESTION D. 6) BINDING AUTHORITIES, UNDERWRITING AND POOL ACTIVITIES

CLASS AND ORIGIN OF BUSINESS

TYPE E.G. B.A. POOL, UNDERWRITING AGENCY

NAME OF INSURERS SUBSCRIBING

MAXIMUM LIMIT

NAME OF DIRECTOR(S) RESPONSIBLE

METHOD OF OPERATION

COMMISSION / FEES

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Description: PROFESSIONAL INDEMNITY PROPOSAL FORM FOR UNDERWRITING AGENTS, POOL