Professional Indemnity insurance

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
Inclusive of VAT and R80.00 broker fee
Inclusive of collection fee R11.40
Excess: R 1,000.00

PUBLIC LIABILITY

Inclusive of VAT and R80.00 broker fee
Excess: R 1,000.00
Extensions:
- Statutory Defence Costs - R100 000.00
- Wrongful Arrest - R100 000.00
- Defamation - R100 000.00

Cover

Indemnity cover*

Liability cover

PERSONAL DETAILS*

First Last

Email*

Identity Number*

REPS SA Memb. No

(Only applicable if a REPSA member)

Postal Address*

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 details*

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 to debit my account with a one off premium payment at:

Bank*

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.

Copy of policy wording available on request.

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Professional Indemnity insurance

LSG Insurance Service (Pty) Ltd

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