ISSUANCE OF BONDS. Application Form SECTION A - GENERAL INFORMATION

Transcription

1 ISSUANCE OF BONDS Application Fm The Jubilee Insurance Company of Tanzania Limited Head Office: Amani Place, Ohio Street, 6th flo P.O. Box 20524, Dar es Salaam Tel: Fax: enquiry@jubileetanzania.com (The liability of the Company does not commence until this proposal has been accepted by the Company and the premium paid.) Infmation given herein will be treated in strict Confidence. Put a ( ) mark wherever applicable. If space is not sufficient in any column, please give details on a separate sheet of paper. Kindly answer all questions completely in der to help us to serve you better. We are desirous of the Company issuing to us a Bonding facility and certify that the following infmation provided below is true and crect. We also agree to undertake to provide you with any changes in the particulars provided below from time to time and also as and when asked by you in relation to the Bonds. SECTION A - GENERAL INFORMATION Bond Type (Please tick) Tender Perfmance Customs Advance Payment Others Company/Firms Name Date Company Established/Incpated Registration Certificate No. (Attach copy of Certificate of Incpation Registration Certificate) Authised Capital Paid Up Capital of Company Do you have copies of Company s Memandum and Articles of Association (Attach copy). Number of Years Company/Firm has been in business Customs Agent Licence Number. (Attach a copy where applicable) Tin No. (Attach a copy of Certificate) VAT Registered No. (Attach copy of Certificate) Registered Office Building Name Flo/Suite Street/Road Name Town Principal Place of Business (if different from above) Building Name Flo/Suite Street/Road Name Town Postal Address Telephone Numbers Mobile Numbers Fax Numbers Address Website URL Do you have any Branches? (If so, provide details) Type of Business Registration (Tick One) Public Limited Liability Company Private Limited Liability Company Partnership Sole Proprietship

2 SECTION B - DIRECTORS/PARTNERS A. Full Name Occupation Nationality Postal address Office phone Residence phone Fax Percentage of Shares held ID/Passpt No. (Attach copy) Pin No. Attach copy) Situation of Residence Any interest held in C & F Agency(if yes, give details) Any business interest in Tanzania (if yes give details) Have you ever been convicted in a Court of Law? (If yes, state nature of charge leading to conviction) B. Full Name Occupation Nationality Postal address Office phone Residence phone Fax Percentage of Shares held ID/Passpt No. (Attach copy) Pin No. Attach copy) Situation of Residence Any interest held in C & F Agency(if yes, give details) Any business interest in Tanzania (if yes give details) Have you ever been convicted in a Court of Law? (If yes, state nature of charge leading to conviction) If there are any me Directs and partners, attach a sheet and provide the infmation as required in SECTION B. SECTION C - DETAILS OF BANKERS Bank Branch Postal Address Town SECTION D : Experience and Professional Background of Principal Officers. Name Qualification Years in C & F Position

3 SECTION E - STAFF DETAILS Number of staff in total Managerial Staff Others SECTION F - BONDED WAREHOUSE DETAILS If Customs Bonds, please give location of the bonded warehouse (s) SECTION G-SUM INSURED Contract Value (US$ / TZS.) Bond Value (US$ / TZS.) SECTION H - PREVIOUS INSURANCE HISTORY Has any company at any time: Declined any proposal submitted? Cancelled your policy? Charged extra premium? Accepted your proposal on special terms and conditions? DECLARATION I/We hereby declare that to the best of my/our knowledge, the infmation provided above is true and crect and undertake to infm you should there be any change of infmation provided above immediately. Date (D/M/Y) Place Authised Signaty IMPORTANT NOTE 1. Specimen copy of the Policy Fm and other terms applicable to risk is available, on request by the Proposer. 2. Please note that the above is f your general infmation only. F further details and specific infmation, please refer to the Policy whose terms and conditions, exceptions, clauses and warranties are applicable to this insurance. 3. The Policy holder shall keep a recd of all infmation including copies of letters supplied to the insurers f the purpose of entering into the contract. A copy of the completed Proposal Fm will be supplied to the Proposer on request after its completion.

4 Annexure I PERSONAL Counter Indemnity In consideration of THE JUBILEE INSURANCE COMPANY OF TANZANIA LIMITED whose registered office is at 6th flo, Amani Place, Ohio Street, Dar es Salaam (hereinafter called the surety) having executed hereafter executing now in future entering into placing arranging directly indirectly Bonds Guarantees and/ Indemnities of whatever nature (hereinafter called Bonds) in favour of: I BOND TYPE BOND PERIOD: FROM TO IN THE SUM OF TZS/USD (hereinafter called the Indemnit) hereby undertake/s as follows:- 1.To indemnify the Surety against all claims and liabilities under any all of the said Bonds and if the Surety is called upon to pay any monies under any all of the said Bonds, to pay on demand to the Surety the full amount of such monies together with all costs and expenses incurred by the Surety in respect thereof. In pursuance of this Counter Indemnity the Surety shall be entitled whenever notification of claim potential claims is received in respect of any one of the said Bonds to call upon the Indemnit to deposit with the Surety the full amount of the said Bond Bonds such deposit deposits shall be paid by the Indemnit to the Surety within 14 days after request in writing and the Surety may use such monies to settle claim claims together with costs and expenses in connection therewith. If there is a surplus in the hands of the Surety after settling all such claims, costs and expenses such surplus shall be refunded fthwith to the Indemnit but if there is a deficiency then the amount of such deficiency shall be paid by the Indemnit to the Surety fthwith upon request in writing. 2.The Surety shall not be obliged befe enfcing this Counter Indemnity to take any steps to recover from any other person whether principal debt guarant any monies due to the Surety n be obliged to enfce any of the Surety s rights in any rights in any der of priity and no time given by the Surety any variation any indulgence release of any obligation as afesaid release of any other security shall in any way reduce otherwise effect the liability of the Indemnit hereunder. 3.If the Surety executes any Bond procures the Execution of any Bond by another Surety reinsures any Bond with Reinsurers executes any Bond with Co- Securities the terms of this Counter Indemnity shall also operate f the benefit of such Procured Securities Reinsurers and/ Co-Sureties. Any such arrangements shall be deemed to be a Bond hereunder and shall not be in any way reduce otherwise affect the liability of the Indemnit to the Surety. 4.If the Counter Indemnity is executed by me than one person, firm cpation the wd Indemnit shall be read in the plural and the liability of each party executing this Counter Indemnity shall be joint and several and the Surety shall be entitled to recover from any one me of the said parties the full amount of the above mentioned deposit deposits other monies due from the Indemnit by virtue of this Counter Indemnity notwithstanding any terms conditions covenants stipulations of Bonds. 5. To pay the Surety befe the expiry of every year of risk, commencing in each case from the date of the relevant Bond until such Bond be discharged, the premium as agreed in respect of each and every Bond granted to us. DATED THIS DAY of, 201 Place Witness Signature Name Signature Name Mobile No. Address Tanzania Passpt No Mobile No. Address Tanzania Passpt No

5 Annexure II - GENERAL Counter Indemnity (On Company letterhead) In consideration of THE JUBILEE INSURANCE COMPANY OF TANZANIA LIMITED whose registered office is at 6th flo, Amani Place, Ohio Street, Dar es Salaam hereinafter called the surety) having executed hereafter executing now in future entering into placing arranging directly indirectly Bonds Guarantees and/ Indemnities of whatever nature (hereinafter called Bonds) in favour of: WE BOND TYPE BOND PERIOD: FROM TO IN THE SUM OF TZS/USD (hereinafter called the Indemnit) hereby undertake/s as follows:- 1.To indemnify the Surety against all claims and liabilities under any all of the said Bonds and if the Surety is called upon to pay any monies under any all of the said Bonds, to pay on demand to the Surety the full amount of such monies together with all costs and expenses incurred by the Surety in respect thereof. In pursuance of this Counter Indemnity the Surety shall be entitled whenever notification of claim potential claims is received in respect of any one of the said Bonds to call upon the Indemnit to deposit with the Surety the full amount of the said Bond Bonds such deposit deposits shall be paid by the Indemnit to the Surety within 14 days after request in writing and the Surety may use such monies to settle claim claims together with costs and expenses in connection therewith. If there is a surplus in the hands of the Surety after settling all such claims, costs and expenses such surplus shall be refunded fthwith to the Indemnit but if there is a deficiency then the amount of such deficiency shall be paid by the Indemnit to the Surety fthwith upon request in writing. 2.The Surety shall not be obliged befe enfcing this Counter Indemnity to take any steps to recover from any other person whether principal debt guarant any monies due to the Surety n be obliged to enfce any of the Surety s rights in any rights in any der of priity and no time given by the Surety any variation any indulgence release of any obligation as afesaid release of any other security shall in any way reduce otherwise effect the liability of the Indemnit hereunder. 3.If the Surety executes any Bond procures the Execution of any Bond by another Surety reinsures any Bond with Reinsurers executes any Bond with Co- Securities the terms of this Counter Indemnity shall also operate f the benefit of such Procured Securities Reinsurers and/ Co-Sureties. Any such arrangements shall be deemed to be a Bond hereunder and shall not be in any way reduce otherwise affect the liability of the Indemnit to the Surety. 4.If the Counter Indemnity is executed by me than one person, firm cpation the wd Indemnit shall be read in the plural and the liability of each party executing this Counter Indemnity shall be joint and several and the Surety shall be entitled to recover from any one me of the said parties the full amount of the above mentioned deposit deposits other monies due from the Indemnit by virtue of this Counter Indemnity notwithstanding any terms conditions covenants stipulations of Bonds. 5.To pay the Surety befe the expiry of every year of risk, commencing in each case from the date of the relevant Bond until such Bond be discharged, the premium as agreed in respect of each and every Bond granted to us. DATED THIS The Common Seal of INDEMNITOR was hereunto affixed and this Indemnity signed in the presence of: SEAL Witness Signature Name Address Tanzania Passpt No Signature Name Address Tanzania Passpt No Witness Signature Signature Name Address Name Address

6 ANNEXURE III - COLLATERAL DECLARATION I/We of P.O Box do hereby solemnly and sincerely state as follows:- 1.That this serves to confirm that I/We, are the rightful owners of the below listed Mot Vehicle/ House / Land. Mot vehicle No..., Chassis No... and Engine No... Title deed No...Plot No...Block. No... 2.That I/We hereby agree that the said mot vehicle/ house shall be used as collateral f a bond executed by The Jubilee Insurance Company of Tanzania Ltd. 3.That in this connection, I/We have furnished The Jubilee Insurance Company of Tanzania Ltd. with the Original Registration Card/ Title Deed which are free from encumbrance. 4.That in case of default to honour our contractual obligations to the insurers, I/We declare that ownership of the mot vehicle/ house will automatically transfer to Jubilee Insurance Company of Tanzania and that the said insurers will be at liberty to dispose off the vehicle/house as they deem fit. I make this Declaration conscientiously believing the same to be true and in accdance with the provisions of the Oaths (Judicial Proceedings) and Statuty Declaration Act This Declaration is made and } Subscribed by... }... Who is known to me personally } DEPONENT This day of 20 } NAME... ADDRESS... SIGNATURE... QUALIFICATION...