Estate Agents indemnity form Agent Sure Premium: R40.00 Binding fee: R20.00 Total Premium: R60.00 per month Limit of Indemnity: R5millionInsured PersonName* First Last Postal Address*Agency Name*Agency Registration Number*Agency Address*Telephone*FaxCell*Email* WebsiteVAT registration number (will be used on invoice)The income disclosed needs to be for a 12 month period and should be in line with your financial year. Accurate income figures are required.In what month did your financial year end?:*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberEstimated annual Commission income for forthcoming year:*0 - 100 000100 - 200 0000200 000 and aboveActual annual Commission income for past year*0 - 100 000100 - 200 0000200 000 and aboveIs there any additional information you wish to provide about your fee income?Who is your current broker?Who are your current insurers / underwriters?When does your current policy expire?What was your last premium paid (inclusive of VAT)?Has any application for insurance of this nature ever been declined, cancelled or has renewal been refused or have special terms been imposed?:*YesNoIf YES, please provide the reason for this below.4. CLAIMS OR CIRCUMSTANCES THAT COULD LEAD TO A CLAIMOver the past 5 years are you aware of the following against you* - Any claim/s being made or settled? - Any circumstance/s that could lead to a claim being reported to Insurers?YesNoIf YES, please provide the reason for this below.After having made full enquiries, are you aware of ANY circumstances, no matter how remote, which may result in any claim being made against you which has not already been reported to Insured's?*YesNoIf YES, please provide the reason for this below.I hereby authorise LSG Insurance Services or its authorised administrator to debit my account with the agreed monthly Insurance premium and collection fee. I understand that should my payment not be received by LSG Insurance Services or its authorised administrator by the 15th, there is no Insurance cover from the 1st day of that month and the Insurance policy will be cancelled, unless prior arrangements have been made.Bank*Branch Code*Branch*Type of account*Account Number*Name of Account Holder*Notice: Debits cannot be raised through FNB Savings, Master Card Holders or account numbers exceeding 13 digitsDebit order date*1st7th15th I/we declare that after proper enquiry the statements and particulars given above are true and that I/we have not miss-stated or suppressed any material fact. I/we agree that this Proposal Form, together with any other material information supplied by me/us shall form the basis of any contract of insurance affected thereon. I/we undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract. I/We understand that submitting this electronic declaration form will from the basis of this contract. Copy of policy wording available on request.