Proposal Form For Attorneys

1. Insured's Details

Name 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/Directors	b) Professional Staff (other than a)	c) All other salaried staff	d) Total

4. Please provide the Gross Fees received during the past three financial years:

Year	Gross Fees

b) Please provide the estimated fees for the coming 12 months.

5. INSURANCE AND CLAIMS HISTORY

5.1 Present or Previously Insured

5.1.1 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 Insurer

Limit 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 Cover

For 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 Experience

For 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):

Year	Nature Of Claim	Claimant's Name	Amount of Claim

8. Corrective Measures

Please describe corrective measures taken to avoid a recurrence of any claim previously notified.

9. Claims Disclosure

Are 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 section

1.) 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) Conveyancing

Tick	Percentage

b) Commercial

Tick	Percentage

c) Estates

Tick	Percentage

d) Criminal Law

Tick	Percentage

e) Matrimonial

Tick	Percentage

f) IP Law

Tick	Percentage

g) MVA / RAF

Tick	Percentage

h) Litigation

Tick	Percentage

i) Investment advice

Tick	Percentage

j) Tax Law

Tick	Percentage

k) Liquidations

Tick	Percentage

l) Trusts

Tick	Percentage

m) Other areas of law (specify)

Tick	Percentage

2.) Limit of Indemnity to be quoted on (select limit you require, give three options)

Option 1	Option 2	Option 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 1	Option 2	Option 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 Name	Staff 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 1	Option 2	Option 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 Name	Staff 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

DD

MM

YYYY