Application

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________________________________________________________________________________________

ADMIRAL PROFESSIONAL UNDERWRITING AGENCY

1st Floor Norwich Ridge                                                                                         PO Box 72057
29 Queens Road                                     Reg. No. 77/00059/07                             PARKVIEW, 2122
PARKTOWN, 2193                               Tel. (011) 484-4344                                  Fax. (011)484-7399

_________________________________________________________________________________________

Introduced by Geoff London & Associates Fax. (021) 434-5836

Pension Fund Trustees Peace of Mind Insurance

Fidelity, Errors and Omissions

Proposal Form

1. Name of Pension Fund :____________________________________________________________

2. Name of Employer Company : _______________________________________________________

3. Postal Address : _________________________________________________________________

________________________________________________________________________________

4. Name of Administrator : ____________________________________________________________

5. How long has Administrator been practicing ? ___________________________________________

6. Date Insurance is to Commence : _____________________________________________________

7. Date Insurance is to be renewable annually : ____________________________________________

8. a) Are any of the Trustees to be covered remunerated solely or partly on a commission earned basis ?

YES NO (Tick One)

b) If YES; give full details, ie. Names, exact position, details of commission rates etc. :

__________________________________________________________________________

c) Number of Trustees:

__________________________________________________________________________

d) Length of Service of each Fund’s Trustees :

__________________________________________________________________________

9. Describe procedure for the appointment of all Trustees and state in particular whether :

a) References are obtained :

__________________________________________________________________________

b) Statements made on application are verified prior to appointment :

___________________________________________________________________________

___________________________________________________________________________

10. The full value of the Assets of the Fund : ______________________________________________

11. Amount of Insurance required : R____________________________________(Minimum R500,000)

12. Do you wish to include the "Reinstatement of Insured Amount" extension ?

YES NO (Tick One)

13. Current Total Monthly Contributions : R______________________________________________

14. Has the Fund ever had any loss or circumstance which falls within the scope of this insurance ?

YES NO (Tick One)

15. State the name and address of the Auditors :____________________________________________

________________________________________________________________________________

16. Is there any record of fraud, dishonesty, bankruptcy or insolvency on the part of any Trustee, either past
or present ?

YES NO (Tick One)

If YES; give details :____________________________________________________________

____________________________________________________________________________

17. Has any Insurer ever :

a) Declined a proposal from you ?

YES NO (Tick One)

b) Refused to renew your Policy ?

YES NO (Tick One)

c) Imposed special terms or conditions ?

YES NO (Tick One)

If YES; please state when and by whom : ________________________________________________

_________________________________________________________________________________

DECLARATION

I/We hereby declare that the above statements and particulars contained
in this Proposal are true and complete, that at the present time, other than as stated,
I/We have no reason to anticipate any claim under the insurance now being requested. I/We
agree that this Proposal and declaration shall be the basis of the contract between me/us
and the Insurers. I/We agree that this proposal together with any other information
supplied by me/us, shall form the basis of any contract of insurance effected thereon, and
shall be incorporated therein. I/We undertake to inform the company of any material
alteration to these facts, whether occurring before or after completion of the contract of
insurance. The Trustees of the Pension Fund have all, to the best of the Fund’s
knowledge and belief, while acting as Trustees always performed their duties
honestly. There has never come to its notice or knowledge any information which in
the judgement of the Fund indicates that any of the said Trustees are dishonest, such
knowledge as any person signing for the Fund may have in respect to his own
personal acts or conduct, unknown to the Fund, is not imputable to the fund.

DATE :________________________________________________________________

SIGNATURE OF ADMINISTRATOR:____________________________________________

SIGNATURE OF AUTHORISED SIGNATORY:____________________________________________________________

Introduced by Geoff London & Associates Fax (021) 434 5836

Proposal Form ALA - Fidelity, Errors, Omissions for Pension Trustees 7/99

Application

Send mail to webmaster with questions or comments about this web site. Last modified: September 07, 1999

Send mail to webmaster with questions or comments about this web site.
Last modified: September 07, 1999