GN LP Proposal Form

Combined Professional Indemnity, Fidelity Guarantee, Misappropriation of Trust Fund
and Third-Party Impersonation Fraud Proposal Form for Legal Practitioners


1. PROPOSER'S RESPONSIBILITY

  • Answer ALL questions fully and do not leave any blank fields.
  • Where a mark is required, please mark the appropriate box with an “X”.
  • Replies such as “see your records”, or “as previously advised” are not acceptable.
  • If the space provided is insufficient, a separate sheet should be attached.
  • Return the completed Proposal Form to your broker.

Please note:

  • If any changes/corrections need to be made to the form, you will need to initial above the amendment.
  • Failure to provide accurate information may affect your ability to lodge a successful claim.
  • If any part of this document is not understood, please contact your broker before you sign it.

2. DISCLAIMER

You must disclose to the Underwriters all information which is material to it in deciding whether to provide insurance cover to you, including any facts or conduct which might lead to a claim being made against you. Failure to do so could affect your cover. If you are in doubt, then rather disclose.

You will be bound by the answers which are given, and by the information provided by you in this Proposal Form. It is, therefore, in your interests to make sure that all information is correct and understood.

Completion of this form does not bind either you, the Underwriters or the Insurer to complete the insurance transaction.

Please note:

You acknowledge that the personal information you supply is provided voluntarily and therefore constitutes specific, voluntary consent to the processing of such information by the Underwriters/the Insurer. Your personal information will be processed for:

  1. general and specific underwriting and risk assessment purposes;
  2. statistical research and/or reporting;
  3. the legitimate interests of the Underwriters/ the Insurer and/or yourself;
  4. any statutory or regulatory compliance (where applicable).

You have the right to request access to, and correction of, your personal information. You can instruct the Underwriters/the Insurer to cease the processing of your personal information at any time and, subject to the requirements of applicable South African law, request that they delete and/or de-identify such personal information.


3. The following documents must be returned with this Proposal Form:

  1. detailed CV
  2. company profile/brochure
  3. professional body membership