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FINANCIAL INSTITUTIONS PROFESSIONAL INDEMNITY PROPOSAL FORM A

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FINANCIAL INSTITUTIONS PROFESSIONAL INDEMNITY PROPOSAL FORM A Powered By Docstoc
					FINANCIAL INSTITUTIONS PROFESSIONAL INDEMNITY PROPOSAL FORM

A. B. C. D.

Answer all questions leaving no blank spaces. If you have insufficient space to complete any of your answers, continue on your headed paper. Please attach last annual Statement and Report and any Interim Report issued since. 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.

E.

Completion of this form does not bind the Proposer or Insurer to complete the insurance transaction. ______________________________________________________________________________ SECTION 1 - GENERAL

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 (incl. postal code):

Postal Address (incl. postal code):

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Name of subsidiary

Location

Date established

Principal Activity

2. 3. 4. 5.

Company registration number Company VAT registration number When did the Proposer start trading? a) Has the Proposer been acquired by another entity, merged or acquired any other business during the last 5 years? If Yes, please give details: YES NO

b)

Does any individual or organisation own more than 10% of the equity? If Yes, please give details:

YES

NO

c)

Has the Proposer provided any new services to its clients during the last 10 years? If Yes, please give details:

YES

NO

d)

Does the Proposer intend to offer any new services to its clients during the next 12 months? If Yes, please give details:

YES

NO

6.

Please provide the following information:
Currently or at last date of interim report At last yearend At previous year-end

i)

Total Deposits

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Currently or at last date of interim report

At last yearend

At previous year-end

ii)

Total Loans and Discounts Total Funds under : a) Discretionary Management b) Non-Discretionary Management

iii)

iv)

Total Assets

7.

State names of all Executive and Non-Executive Directors, their length of service, specific responsibilities and professional qualifications: Name Length of Service Specific responsibilities Professional Qualifications

8.

a)

State the number of employees in the following categories: RSA
i) ii) iii) iv) v) vi) At Head Office At Data Processing Centre at Branches at Subsidiaries at Agencies at Administration Centre Total :

Elsewhere

b)

State the number of locations:

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c)

What has been the percentage turnover in the following employment categories during the last twelve months the number of locations: Inward
Directors (including those of Subsidiaries) % %

Outward
% %

Employees d)

State the total of salaries, including commissions, paid to Directors and Employees during the last financial year:

B.

PROPOSER'S ACTIVITIES In the last financial year what approximate percentage of the Proposer's total revenues were derived from the following activities?
a) Commercial Loans Interbank Loans Personal Loans b) c) d) e) f) g) h) i) j) k) l) m) n) o) p) q) Leasing Trade Financing Barter, Countertrade or Swap Operations Foreign Exchange Dealings Commodity Market Dealings Mergers and Acquisitions Advice Share Placing and New Issues Fund Management Factoring Venture Capital Overseas Advisory Stockbroking Trust Administration Life Assurance Short-term Insurance Any Other Activity Domestic Foreign Domestic Foreign % % % % % % % % % % % % % % % % % % % % %

Please describe:

Please attach an organisational chart showing responsibilities and reporting lines to the Board of Directors for each activity.

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C.

LOSS EXPERIENCE Please give in the space provided below, brief details of any losses which you have sustained during the past five years and/or any circumstances likely to give rise to a loss or losses whether insured or uninsured.
Date discovered Amount Actual or Estimated

Location

Nature of Loss

Unless the information has been provided above, please attach full details of remedial action taken to avoid recurrence of the said losses.

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SECTION 2 - PROFESSIONAL INDEMNITY A. PARTICULARS OF COVERAGE 1. State details of similar insurances carried during the previous five years, if any: a) Professional Indemnity i) ii) iii) 2. Insurers Sum Insured Deductible

State the Limit/s of Indemnity requested: R State the Deductible/s requested:: R R YES NO R

3.

During the last 5 (five) years has the Proposer received any admonishment or critical directive from any regulatory authority? If Yes, please give details:

4.

Is the Proposer currently involved in any litigation as a defendant which relates to any professional indemnity incident? If Yes, please give details:

YES

NO

5.

a)

Has any application made by the Proposer, or its predecessors in business, for Professional Indemnity Insurance ever been declined? If Yes, please give details:

YES

NO

b)

Has any Professional Indemnity Policy in the name of the Proposer or its predecessors in business ever been cancelled? If Yes, please state reasons:

YES

NO

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B.

LEGAL ADVISORS 1. State the names of external legal advisors routinely acting for the Proposer:

2.

Do the legal advisors supply written opinions as to the legality of any change in investment or management policy in connection with trusteeship activities? Do the Proposer have an in-house Legal Department? If Yes, how many legally qualified individuals does it consist of? What are the Department’s responsibilities?

YES

NO

3.

YES

NO

4.

Does it offer its services to customers or other Third Parties? If Yes, please give details:

YES

NO

5.

Does the Proposer use a standard form of contract, agreement or letter of offer setting out the terms and condisions of the services performed? If Yes, a) b) Are all contracts approved by legal advisors? Do contracts provide indemnity and/or limitations to the Proposer’s liability?

YES

NO

YES YES

NO NO

6.

Are all publications, marketing material, or other product services communications issued by the Proposer reviewed by the in-house Legal Department and/or outside legal advisers prior to their release to third parties?

YES

NO

C.

DISASTER RECOVERY Does the Proposer have a comprehensive disaster recovery plan? If No, indicate the procedures in place for disaster recovery YES NO

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D.

ACTIVITIES 1. a) List each takeover or merger situation in which the Proposer acted on behalf of clients in the last twelve months, indicating by asterisk, on behalf of whom the Proposer was acting, and the values involved. Offeror Outcome Offer Value

Total: b) How many flotations has the Proposer undertaken in the last twelve months? List each indicating the share capital involved. Company Shares Placed Value

Total:

c)

How many rights issues has the Proposer undertaken in the last twelve months? List each, indicating the share capital involved. Company Shares Placed Value

Total:

2.

Does the Proposer undertake trust activities or discretionary account management? If Yes, a) b) Are all clients’ agreements reviewed annually? Are all trust/discretionary transactions subject to the same procedures and review as the Proposer's own account transactions? If No, please describe:

YES

NO

YES YES

NO NO

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c)

State: i) ii) The number of trust/discretionary accounts The asset value of the largest managed account

d) e)

How often are financial reports rendered to clients? Does the Proposer have an "approved" list of investments/securities which can be recommended to clients? YES NO

3.

Is the Proposer involved in fund or investment management activities? If Yes, a) Does the Proposer currently maintain a manual containing a written investment policy? Are trading transactions and positions reviewed for compliance with formal trading policies manual? Are accounts of trades which exceed set limits identified or rectified or referred to senior management for immediate action? Do counterparties receive authorised confirmation for all deals prior to settlement? Are responsibilities for investment decisions segregated from accounting activities and custodial responsibilities?

YES

NO

YES

NO

b)

YES

NO

c)

YES

NO

d)

YES

NO

e)

YES

NO

4.

Is the Proposer involved in providing insurance services? If Yes, a) Do you have and maintain a formal underwriting manual for all classes of insurance? What is the percentage of business production in the following areas? i) ii) iii) iv) c) d) e) agents direct sales brokers other, please specify

YES

NO

YES

NO

b)

Are payments made directly to you? Do you have an IGF? Do you have a FAIS licence?

YES YES YES

NO NO NO

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f) g)

Is the responsibility for the claims department totally segregated from underwriting? Are the claims reviewed and agreed by a minimum of two authorised individuals before payment is made direct to the Insured?

YES YES

NO NO

E.

EXTERNAL AUDIT 1. State the name of the independent firm of Chartered Accountants or Professional Auditors or other competent Authority who fully audit your Accounts annually.

In addition please state: a) b) Frequency of audit (if other than annual): _____________________ Does the audit include all Institution offices, including all Data Processing Centres? If Not, what extent does the audit take? YES NO

c)

Do the auditors visit all the branches? If Not, please state frequency of visits to branches?

YES

NO

d)

Does the firm or Authority regularly review the system of internal control and furnish written reports? If Yes, do these reports go directly to the Board of Directors?

YES

NO

e)

Has the Auditing Firm made any recommendations in the last two audits? If Yes, please state recommendations and confirm that they have been adopted. If not adopted, please give reasons for not doing so, alternatively please provide the management response?

YES

NO

f)

Has the Auditing Firm rendered an unqualified opinion for each of the last five years? Has the Auditing Firm been changed in the last five years?

YES

NO

g)

YES

NO

If yes, please give details and explain why the change was made.
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h)

Has the Proposer complied with all recommendations made as a result of its most recent audit?

YES

NO

If No, have you adopted alternative arrangements to the satisfaction of your auditor?

i)

Are all entities subject to the same external audits and applicable internal controls, procedures and appropriate physical security standards? If No, please provide full details?

YES

NO

F.

INTERNAL AUDIT Is there an Internal Audit Department that is separate from the auditing services provided by an external auditor ? If No, how is this function performed? YES NO

If Yes,

a) b) c) d) e) f)

Is there an "audit and control procedures" manual? How many people are employed in the Internal Audit Department? Have they been trained to fulfull this function? How often are full internal audits conducted? Are audits made regularly on a surprise basis? Are all premises, including computer centres and facilities included in the audit? Are the personnel responsible for the auditing free of all other operational responsibilities and forbidden to originate entries? Is the internal audit department independent of any other function? Does the Internal Auditor report directly to the Audit Committee of the Board of Directors?

YES

NO

YES

NO

YES YES

NO NO

g)

YES

NO

h)

YES

NO

i)

YES

NO

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j)

Do you have procedures in place to monitor the implementation of recommendations made by the internal audit department? If No, how is this function performed?

YES

NO

G.

COMPLIANCE PRACTICES 1. Does the Proposer have a Compliance Officer? If Yes, please state his/her duties and to whom he/she reports: YES NO

Please attach relevant curriculum vitae. 2. a) Does the Proposer have a written code of ethics encompassing all employees which includes a statement on the principles of acceptable conduct, and with guidelines for acceptable outside activities, conflict of interests, gifts from customers and prohibition on other employment? Are employees required to agree in writing that they have read the ethics code and are abiding by said code? Do you require all Directors and Employees to declare their outside business interests and specify relationships which could lead to possible conflicts of interest? Does the Proposer currently maintain a manual containing a standard procedure for investigating and verifying employees prior to their employment ? YES NO

b)

YES

NO

c)

YES

NO

d)

YES

NO

H. 1.

INDEPENDENT CONTRACTORS Does the Proposer utilise independent contractors? YES NO

2.

Does the Proposer obtain a written agreement from the independent contractors outlining their responsibilities? Does the Proposer require all independent contractors to obtain separate insurance? If Yes, for what minimum amount?

YES

NO

3.

YES

NO

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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: ___________________________________ Chief Executive Officer (or other Senior Officer if the Chief Executive Officer is also the Chairman, Board of Directors) ___________________________________ Chairman, Board of Directors ___________________________________ Group Risk Manager 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.

Phoenix – FIPI – Oct 2007


				
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Description: FINANCIAL INSTITUTIONS PROFESSIONAL INDEMNITY PROPOSAL FORM A