Professional Indemnity insurance

PLEASE READ DISCLOSURE NOTICE
Activities Covered: Personal Training, Group Training, Health and Fitness Professionals
Administered By: LSG Insurance Services (Pty) Ltd a subsidiary of PSG Insure – Steenberg (Licence No.728) -+27 (0)21 701-0840
Jurasdiction: Worldwide Excluding USA and Canada

Public Liability Insurance inclusive of Professional Indemnity Insurance

Cover

Indemnity cover*

Swimming Instructors Cover

Playball Franchisors Cover

Playball Coaches Cover

PERSONAL DETAILS*

First Name

Surname

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*

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 FOLLOWING

1. 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 RSUM Liability Specialists) 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 digits

Once 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 R50.00 broker fee* .*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:
1. Process your personal information to
  1. Communicate information to you that you ask us for.
  2. Provide you with insurance services.
  3. Verify the information you have given us against any source or database.
  4. Compile non-personal statistical information about you.
2. 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.
3. Transmit your personal information to any third party service provider that we may appoint to perform functions relating to your policy on our behalf.
4. You acknowledge that this consent clause will remain in force even if your policy is cancelled or lapsed.
5. By clicking submit I agree to appoint PSG Wealth Financial Planning to provide me with financial services & I give consent to PSG to contact me using the above provided contact details. I understand that PSG is authorised to obtain, process, share, store and retain all of my personal information, in so far as is reasonably required, to give effect to my instructions and to enable PSG to offer proper financial services and give advice. FSP 728

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Professional Indemnity insurance

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