Professional Indemnity insurance Activities Covered: Personal Training, Group Training, Health and Fitness Professionals Administered By: LSG Insurance Services - 086 111 5140 Jurasdiction: Worldwide Excluding USA and Canada Excess: R 1,500.00 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: R1500.00 PUBLIC LIABILITY Inclusive of VAT and R80.00 broker fee Excess: R1500.00 Extensions: Statutory Defence Costs - R100 000.00 Wrongful Arrest - R100 000.00 Defamation - R100 000.00 CoverIndemnity cover*select Indemnity cover1 million - premium R 4661.5 million - premium R 5512 million - premium R 6123 million - premium R 6844 million - premium R 7455 million - premium R 7996 million - premium R 9067 million - premium R 11378 million - premium R 13029 million - premium R 163210 million - premium R 1852Liability cover*select liability cover1 million - premium R 2861.5 million - premium R 2952 million - premium R 3123 million - premium R 367PERSONAL DETAILS* First Last Email* Identity Number*REPS SA Memb. No*Postal Address*Business Phone*Home PhoneCell*TYPE OF INSTRUCTION GIVEN* (Tick Relevant Box) Personal Trainer Swimming Group Trainer Walking Other (Please state) OtherName of Club*Name of Fitness Manager*Fax NumberPLEASE COMPLETE THE FOLLOWING1. Have any claims ever been made against you?*yesnoIf Yes, please give detail2.Are you aware of any circumstance/incident which may have taken place which may result in a claim?:*yesnoIf yes, please give details*3. For the type of insurance being proposed, has an insurer ever: Declined Proposal or Renewal:*yesnoImposed special terms:*yesnoRequired an increased premium:*yesno*yesnoI hereby authorise LSG Insurance Services Pty (Ltd) and its administrators Innovation Maven Pty (Ltd) 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 digitsOnce Off Debit Date:*1st7th15thAmount 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.