AIG South Africa. Liabilities Group P ROPOS AL FORM

Transcription

1 AIG South Africa Liabilities Group LIABILITY INSUR ANCE P ROPOS AL FORM

2 General section Primary Insured s information Name of Insured: Main Physical Address: Website Address: Current Insurer Name: Business description Years in business Number of years in business: Company registration number: Details of subsidiaries Please list the company names of your subsidiaries/joint ventures and a brief description of their business in the table below and tick Yes or No if Insurance is required under this programme: SUB # COMPANY OR JOINT VENTURE NAME BUSINESS DESCRIPTION INSURANCE REQUIRED UNDER THIS PROGRAMME? 1. YES NO 2. YES NO 3. YES NO 4. YES NO 5. YES NO Continued on next page

3 General section, Continued Details of sold assets Are there any companies or joint ventures which the insured has disinvested/sold? (Please Tick) YES NO Details of all premises Please provide details for main premises including the main physical address listed above: LOC # LOCATION OF PREMISES, EG DURBAN, BOTSWANA? TYPE OF PREMISE, EG FACTORY, WAREHOUSE, OFFICE? INTEREST? NO. OF OCCUPANTS PER PREMISE? DESCRIPTION OF SURROUNDING AREA ALL FOUR SIDES? Claims Experience Please list all general and tenants claims or reported incidences for the years listed in the table below: YEAR NUMBER OF CLAIMS / INCIDENTS? TOTAL VALUE OF CLAIMS / INCIDENTS? CATEGORY DESCRIPTIONS, EG 3 RD PARTY - BODILY INJURY OR PROPERTY DAMAGE?

4 Product Liability section Definition Products means any goods or products manufactured, constructed, repaired, serviced, treated, sold, supplied or distributed by the Policyholder after they have ceased to be in the possession or under the control of the Insured, including any container thereof or instructions provided therewith. Turnover Please provide the turnover figures and the additional information for the company/group of companies for the years listed in the table below: YEAR ESTIMATE OR AUDITED? TURNOVER FIGURE? PERCENTAGE TURNOVER GENERATED FROM OPERATIONS OUTSIDE SOUTH AFRICA? Turnover breakdown Please provide the turnover breakdown by Product and/or Company division or Subsidiary for the years listed in the table below: YEAR PRODUCT/COMPANY DIVISION OR SUBSIDIARY? PERCENTAGE OF Current GROUP TURNOVER? Prior Continued on next page

5 Product Liability section, Continued Export pattern breakdown Please provide the export pattern by product, country and percentage turnover: YEAR PRODUCT? COUNTRY/S? PERCENTAGE OF Current GROUP TURNOVER? Prior Product/raw material supplies Please provide details of your product/raw material supplies as per the table headings below: PRODUCT/RAW MATERIAL DESCRIPTION IMPORTED (PLEASE TICK IF YES) SOURCED IN SOUTH AFRICA (PLEASE TICK IF YES) IF IMPORTED, PLEASE STATE NAME OF COUNTRY/S? Agreements with suppliers Please answer the below questions by ticking yes or no: YES NO Does your company use standard contract terms of trade? Has your company or any division or subsidiary concluded hold harmless agreements with one or more suppliers? Continued on next page

6 Product Liability section, Continued Claims Experience Please list all product liability claims or reported incidences for years listed in the table below: Note: As a minimum, we require 5 years claims experience, non-concurrent 5 years is also acceptable. YEAR NUMBER OF CLAIMS / INCIDENTS? TOTAL VALUE OF CLAIMS / INCIDENTS? CATEGORY DESCRIPTIONS, EG 3 RD PARTY - BODILY INJURY OR PROPERTY DAMAGE OR PRODUCT RECALL Employers liability Definition Employee details Employee means: (a) any person under a contract of service or apprenticeship with the Policyholder; (b) any labour master or labour only sub-contractor or person supplied by them; (c) any self-employed person; (d) any person hired or borrowed by the Policyholder from another employer under an agreement by which the person is deemed to be employed by the Policyholder; (e) any person under a work experience or similar scheme (f) while engaged and working under the direction and control of the Policyholder in connection with and in the course of the Business. Please complete the information requirements as listed in the table below: NUMBER OF EMPLOYEES IN THE GROUP? NUMBER OF CLERICAL EMPLOYEES? NUMBER OF MANUAL EMPLOYEES? NUMBER OF EMPLOYEES WHO WORK OFFSITE? TOTAL SALARY BILL FOR GROUP? SALARY BILL FOR CLERICAL EMPLOYEES? SALARY BILL FOR MANUAL EMPLOYEES? SALARY BILL FOR EMPLOYEES WHO WORK OFFSITE?

7 Claims Experience Please list all employers liability claims or reported incidences for years listed in the table below: YEAR NUMBER OF CLAIMS / INCIDENTS? TOTAL VALUE OF CLAIMS / INCIDENTS? CATEGORY DESCRIPTIONS, EG EMPLOYEE INJURY OR EMPLOYEE TO EMPLOYEE INJURY Policy requirements Limits of indemnity Please complete the information requirements as listed in the table below: General and s COVERAGE LIMIT REQUIRED? DEDUCTIBLE? Products Liability Employers Liability Wrongful arrest and defamation Gratuitous Negligent Advice Statutory legal defence costs Legal defence costs Policy trigger Please note the policy trigger and retroactive date, in the space below: PLEASE TICK CLAIMS MADE? LOSSES OCCURRING? IF CLAIMS MADE, PLEASE PROVIDE RETROACTIVE DATE?

8 Additional Coverages Please list the additional coverages required, in the space below: Policy territory and jurisdiction Please note the policy territory and jurisdiction required, in the space below: TERRITORY? Declaration JURISDICTION? If there is any information which is relevant to the risk, which we have not covered in this proposal form, please describe these in detail in the space provided below: I understand that the answers provided to the questions contained in this questionnaire and any additional information provided and any documentation submitted in support of this document, will form the basis of any policy or policies effected. I confirm that the information and documentation submitted, is correct, to the best of my knowledge. SIGNED (On behalf of the Proposer Joint Signatories Permitted) CAPACITY DATE End of proposal form