Estate Agents indemnity form Agent Sure Premium Table Revenue Per Annum Limit of R1m Annual Premium Limit of R1m Monthly Premium Limit of R2.5m Annual Premium Limit of R2.5m Monthly Premium Limit of R5m Annual Premium Limit of R5m Monthly Premium R1 – R500k 5,500 505 9,500 870 14,000 1,285 R500k - R1m 6,000 550 10,000 915 14,500 1,330 R1m - R1.5m 6,500 595 10,500 965 15,000 1,375 R1.5m - R2m 7,000 642 11,000 1,010 15,500 1,420 Excess: R10,000 For revenue per annum in excess of R2m please refer to firstname.lastname@example.org Extentions Cover First Amount Payable Limit of Indemnity Loss of Documents R25,000 5% of the main PI limit of indemnity maximum R500,000 in the aggregate Defamation (Libel and Slander) R10,000 R1,000,000 in the aggregate Statutory Defence Costs Nil R 250,000 in the aggregate Risk Management Services Included Service Benefit to Client Crisis Communication & PR Public relations support and media disaster management Legal Support Contract vetting and management Private Arbitration Alternative options to costly litigation in commercial and employment disputes Insured PersonName* First Last Policy Holder Protection Data (Compulsory)Is the Insured’s annual Turnover or Asset Value LESS than R 2,000,000?* Yes No Postal Address*Agency Name* Agency Registration Number* Agency Address*Telephone* Fax Cell* Email* Website 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?:* Yes No If 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? Yes No If 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?* Yes No If 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* 1st 7th 15th 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. I/We understand that the Binding Fee included in the premium relates to services provided and hereby consent to such fee. Insurance is not bound until accepted by insurers Only property in South Africa I/We understand that in order to provide you with insurance, we must process your personal information. We will share your personal information with other insurers, industry bodies, credit agencies and service providers. This includes information about your insurance, claims and premium payments. We do this to provide insurance services, prevent fraud, assess claims and conduct surveys. We will treat your personal information with caution and have put reasonable security measures in place to protect it. By electronically submitting this form, you agree to the processing and sharing of your personal information. Copy of policy wording available on request.