Professional Indemnity insurance PLEASE READ DISCLOSURE NOTICE Activities Covered: Personal Training, Group Training, Health and Fitness Professionals Administered By: LSG Insurance Services -+27 (0)21 701-0840 Jurasdiction: Worldwide Excluding USA and Canada Excess: R 1,000.00 each and every claim PROFESSIONAL INDEMNITY Inclusive of R1 000 000 Public Liability cover Excess: R 1,000.00 PUBLIC LIABILITY Excess: R 1,000.00 Extensions: Statutory Defence Costs – R100 000.00 Wrongful Arrest – R100 000.00 Defamation – R100 000.00 CoverIndemnity cover*select Indemnity cover1 million - premium R 5981.5 million - premium R 7082 million - premium R 7853 million - premium R 8784 million - premium R 9585 million - premium R 10286 million - premium R 11667 million - premium R 14608 million - premium R 16759 million - premium R 209510 million - premium R 2310Online Instruction (Optional Extension to Indemnity Cover)select Indemnity cover1 million - premium R 578Liability coverselect liability cover1 million - premium R 3451.5 million - premium R 3812 million - premium R 4043 million - premium R 472Swimming Instructors Coverselect liability cover1 million - premium R 520PERSONAL DETAILS*First Name SurnameSurname Policy Holder Protection Data (Compulsory)Is the Insured’s annual Turnover or Asset Value LESS than R 2,000,000?* Yes No What is the Present Legal Constitution of the Insured ?* Sole Practitioner Partnership Incorporated Co. Limited Co. Closed Corp. Email* Identity Number* REPS SA Memb. No(Only applicable if a REPSA member) Postal Address*Street Address Street Address 2*Street Address 2 City*City Postal Code*Postal Code Business Phone* Home Phone Cell* TYPE OF INSTRUCTION GIVEN* (Tick Relevant Box) Personal Trainer Swimming Group Trainer Other (Please state) Other Name of Club* Name of Fitness Manager* Fax Number PLEASE COMPLETE THE FOLLOWING1. Have any claims ever been made against you?* yes no If Yes, please give detail 2.Are you aware of any circumstance/incident which may have taken place which may result in a claim?:* yes no If Yes, please give detail 3. For the type of insurance being proposed, has an insurer ever: Declined Proposal or Renewal:* yes no Imposed special terms:* yes no Required an increased premium:* yes no Cancelled insurance* yes no I hereby authorise LSG Insurance Services Pty (Ltd) and or its authorised administrators (on behalf of insurers Santam Ins Co Ltd) to debit my account with a one off premium payment at:Bank* Name of Branch* Branch Code* Account Holder* Account Number* Account Type* NOTE: Debits cannot be raised through FNB Savings, Master Card Holders, or account numbers exceeding 13 digitsOnce Off Debit Date:* 1st 7th 15th Amount to be debited* 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 premium includes regulated commission, charged at 20% of the gross premium, payable to the broker for services provided. I/we consent to a R80.00 broker fee* and either a R11.40 debit order charge or R15.00 cash deposit charge (whichever is applicable).*Explained in LSG Financial Services Guide. Insurance is not bound until accepted by insurers. Insurers share information with each other regarding policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. By reducing the incidents of fraud and assessing risks fairly, future premium increases may be limited. This is done in the public interest and in the interest of all current and potential policyholders. The sharing of information includes, but is not limited to information sharing via the Information Data Sharing System operated by TransUnion ITC on behalf of the South African Insurance Association. By the insurer accepting this insurance, you or any other person that is represented herein, gives consent to the said information being disclosed to any other insurance company or its agent. You also similarly give consent to the sharing of information in regards to past insurance policies and claims that you have made. You also acknowledge that information provided by yourself or your representative may be verified against any legally recognised sources or databases. By insuring you hereby not only consent to such information sharing, but also waive any rights of confidentiality with regards to underwriting or claims information that you have provided or that has been provided by another person on your behalf. In the event of a claim, the information you have supplied with your application together with the information you supply in relation to the claim, will be included on the system and made available to other insurers participating in the Information Data Sharing System. When you enter into this policy you will be giving us your personal information that may be protected by data protections legislation, including but not only, the Protection of Personal Information Act, 2013 (“POPI”). We will take all reasonable steps to protect your personal information. You authorise us to: Process your personal information to Communicate information to you that you ask us for. Provide you with insurance services. Verify the information you have given us against any source or database. Compile non-personal statistical information about you. Transmit your personal information to any affiliate, subsidiary or re-insurer so that we can provide insurance services to you and to enable us to further our legitimate interests including statistical analysis, re-insurance and credit control. Transmit your personal information to any third party service provider that we may appoint to perform functions relating to your policy on our behalf. You acknowledge that this consent clause will remain in force even if your policy is cancelled or lapsed.