Combined Professional Indemnity, Fidelity Guarantee and Misappropriation of Trust Fund Cover Proposal Form for Attorneys 1. Insured's DetailsName of insured Contact person Physical Address (Main office)Telephone Email Address Vat Reg. Number 2. Firm To Be Insured (Mark Relevant Box Below) Sole Practitioner Partnership (Pty) Limited) Incorporated Partnership 3. Total Number Of Staff:a) Partners/Principals/Directorsb) Professional Staff (other than a)c) All other salaried staffd) Total 4. Please provide the Gross Fees received during the past three financial years:YearGross Fees b) Please provide the estimated fees for the coming 12 months.5. INSURANCE AND CLAIMS HISTORY5.1 Present or Previously Insured5.1.1 Are you in the present or have you in the past been insured,for the type of insurance now being proposed?* Yes No If Yes Please state InsurerLimit of Indemnity Premium Cover expiry date Retroactive date 5.1.2) If you are not currently insured please state the date you would like the policy to incept (subject to acceptance) 6. Declined CoverFor Professional Indemnity, Fidelity Guarantee or Misappropriation of trust funds, has any insurer ever:a) declined a proposal or renewal for this firm? Yes No b) required an increased premium or imposed special terms? Yes No C) cancelled a policy of insurance? Yes No 7. Claims ExperienceFor Professional Indemnity, Fidelity Guarantee or Misappropriation of Trust Funds Insurance, have any claims been made in the last 5 years against the firm for the type of cover for which you are now applying? Yes No If YES, please provide us with details below (attach a back page if necessary):YearNature Of ClaimClaimant's NameAmount of Claim 8. Corrective MeasuresPlease describe corrective measures taken to avoid a recurrence of any claim previously notified.9. Claims DisclosureAre any of the Proposed Insured/Partners/Directors or Employees, AFTER ENQUIRY, aware of any circumstances which could give rise to a claim under a policy of this type? Yes No Part A: Professional Indemnity section1.) Nature of legal services provided and Income derived from such services Please indicate the type of legal services performed and the approximate percentage of the total income derived in the previous financial year from:a) ConveyancingTickPercentage b) CommercialTickPercentage c) EstatesTickPercentage d) Criminal LawTickPercentage e) MatrimonialTickPercentage f) IP LawTickPercentage g) MVA / RAFTickPercentage h) LitigationTickPercentage i) Investment adviceTickPercentage j) Tax LawTickPercentage k) LiquidationsTickPercentage l) TrustsTickPercentage m) Other areas of law (specify)TickPercentage 2.) Limit of Indemnity to be quoted on (select limit you require, give three options)Option 1Option 2Option 3 PLEASE NOTE: You are proposing for TOP UP cover. All Attorneys enjoy an annual amount of indemnity with the Legal Practitioners’ Indemnity Insurance Fund (“the Primary Insurer”) according to the number of principals in the firm. If for any reason whatsoever, the Primary Insurer does not cover a claim/loss under its Master Policy (as reviewed from time to time), then the TOP UP Policy will also not be called into contribution for the claim, unless the Insured has selected an extension offered by the Insurer and not the Primary Insurer. This Policy will only be called upon where a claim which is the subject of indemnity under this Policy exceeds the maximum level of indemnity which the Insured recives from the Primary Insurer. The Insured is to clearly indicate in 3. below the optional PI extensions which are required; 3.) Optional PI Extensions (to be charged for)LPIIF Excess Infill Yes No Correspondent Attorneys Yes No Cyber Liability Extension Yes No Investment Advice Extension Yes No Outside Directors & Officers Yes No Part B Fidelity Guarantee (only complete if cover is required)1. Do you obtain written references from previous employers in respect of your employees who are responsible for either cash collections, any accounts or finance functions, and/or computer operations? Yes No N/A 2. Do you provide receipts for all business payments received? Yes No N/A 3. Are the employees who are responsible for the collection of business funds and the banking thereof different people? Yes No N/A 4. Is your petty cash regularly checked by someone other than that person who controls it? Yes No N/A 5. Is receipting done at the time that funds are received? Yes No N/A 6. Do all business cheques drawn required 2 or more signatures? Yes No N/A 7. Do all business payments transactions require 2 or more authorisations? Yes No N/A 8. Limit of Indemnity to be quoted on (select limit you require, give three options)Option 1Option 2Option 3 9.a. Blanket Basis Yes No 9.b. Named Persons Basis/Named Positions Basis Yes No If cover is selected on a Named Persons Basis or Named Positions Basis, then please provide a list of the staff/positions to be covered under this section of the policy.Staff Member's NameStaff Member's Position 10.) Optional FG Extensions (to be charged for)Retroactive cover extension - No previous insurance in force Yes No Superseded insurance extension Yes No Voluntary first amount payable clause Yes No Reduction/reinstatement of insured amount clause Yes No Costs of recovery extension Yes No Computer losses extension Yes No Extension for losses discovered more than 24 (twenty four) months after being committed but not more than 36 (thirty six) months thereafter Yes No Extension granted on receipt of a satisfactory systems audit in respect of losses discovered more than 24 months after being committed (if stated in the schedule to be included) Yes No * Should you have selected NO or N/A to questions 1-7, please provide further details.PART C Misappropriation of Trust Fund Cover (only complete if cover required)1. Please tick the system used to manage your Trust Fund Account:* Nedbank Corporate Saver Nedbank Pro Banker Standard Bank Third Party Fund Administration First National Bank Investec Corporate Cash Manager Other (please specify) 2. Please provide us with the maximum anticipated amount that will be held in your Trust Fund Account at any one time during the insurance period 3. Do you obtain written references from previous employers in respect of your employees who are responsible for either cash collections, any accounts or finance functions, and/or computer operations? Yes No N/A 4. Are the employees who are responsible for the collection of business funds and the banking thereof different people? Yes No N/A 5. Do you provide receipts for all trust payments received? Yes No N/A 6. Are all payments received recorded? Yes No N/A 7. Do all trust cheques drawn require 2 or more signatures? Yes No N/A 8. Are all blank trust cheques, cheque books and requisitions kept under lock and key? Yes No N/A 9. Limit of Indemnity to be quoted on (select limit you require, give three options)Option 1Option 2Option 3 10.a. Blanket Basis Yes No 10.b. Named Persons Basis/Named Position Basis Yes No If cover is selected on a Named Persons Basis or Named Positions Basis, then please provide a list of the staff/positions to be covered under this section of the policy.Staff Member's NameStaff Member's Postion 11. Optional MOTF Extensions (to be charged for)Insolvency Practitioners extension (applicable to attorney firms only)* Yes No * Should you have selected NO or N/A to questions 3-8, please provide further details. Declaration I/We hereby declare that the above statements and particulars contained in this Proposal are true and complete and that at the present time, other than stated, I/We have no reason to anticipate any claim under the insurance now being requested. I/We agree that this proposal, together with the Policy Wording, the Schedule, this declaration and all previous correspondence shall be the basis of the contract between me/us and the Insurers.Yes I Agree Yes Date Day Month Year
