Combined Professional Indemnity, Theft of Third Party Monies and Third Party Impersonation Fraud Insurance for Financial Service Providers>
- Answer ALL questions fully and do not leave any blank fields. It is important that all information contained in this proposal is understood by you and is correct, as you will be bound by your answers and by the information provided by you in this proposal.
- If any changes/ corrections need to be made to the form, you will need to initial above the amendment.
- If any part of this document is not understood, please contact your Broker before you sign it.
- Return the completed proposal form to your broker.
- You have a duty to disclose to the Insurer every matter that you know, or could reasonably be expected to know, is relevant to the Insurer’s decision whether to accept the risk of the insurance, and, if so, on what terms. Failure to provide accurate information may affect your ability to lodge a successful claim.
- Your duty of disclosure continues after the proposal has been completed up until the contract of insurance is entered into, whereafter this clause is replaced with the Policy Wording disclosure conditions.
- You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate the contract of insurance.
- Signature of this Proposal does not bind the Proposer/ Insurers to complete the insurance.
- The completed proposal form must be submitted prior to inception / renewal of the policy.
- This is a Claims Made Policy, i.e. the policy must be in force when a claim is first made.
- This is an annual policy which shall be renewed annually.
- Failure to provide accurate and truthful information may affect your ability to claim successfully.
- If the space provided is insufficient, please make use of the separate sheet attached hereto.
6. You acknowledge that the personal information you supply is provided voluntarily and therefore constitutes specific, voluntary consent to the processing of such information by Genoa / Safire. Your personal information will be processed for:
- General and specific underwriting and risk assessment purposes;
- Statistical research and / or reporting;
- The legitimate interests of Genoa / Safire and / or yourself; and
- Any statutory or regulatory compliance (where applicable).
7. You have the right to request access to, and correction of, your personal information. You can instruct Genoa / Safire to cease the processing of your personal information at any time and, subject to the requirements of applicable South African law, request that Genoa / Safire delete and/or de-identify such personal information.
1. INSURED’S DETAILS
If you have more than one
office and require cover to
be extended, please provide
the address of such other office
Are you a Juristic Representative? If YES, please provide further details
Do you carry out any business outside of the borders of South Africa? If YES, please provide further details
Are you involved in any Joint Venture Appointments? If YES, please provide further details
2. Number of Staff