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Professional Indemnity Proposal Form for Technology Industry

This proposal is for a CLAIMS MADE policy

The policy will only respond to claims and/or circumstances, which are first made against the Insured and notified to the Insurer during the policy period. The policy will not provide cover for:-

Events that occurred prior to the retroactive date of the policy. Claims made after the expiry of the policy period even though the Wrongful Act giving rise to the claim may

have occurred during the policy period. Claims notified or arising out of facts or circumstances notified under any previous policy or noted on the

current proposal form or any previous proposal form. Claims made, threatened or intimated prior to the commencement of the policy period.

Facts or circumstances in your knowledge prior to the policy period, which you knew had the potential to give rise to a claim under the policy.

DISCLOSUREYou must disclose to the Insurer all information which is material to it in deciding whether to issue insurance cover to you, including any facts or conduct which might lead to a claim being made against you. Failing to do so could

affect your rights to indemnity.

If you do not understand any part of this document, please contact your Broker BEFORE YOU SIGN IT. You will be bound by the answers, which are given, and by the information provided by you in this proposal form. It is in your

interest to make sure that all information is correct and properly understood.

When in doubt disclose

ATTACHMENTSBefore you return this form, have you included the following (please indicate by ticking the boxes):Company brochure/ additional information:

Claims information (if relevant):

Please attach details where not enough space on the proposal

Stalker Hutchison Admiral (Pty) Ltd

Tel: +27 (0)11 731 3600Fax: +27 (0)86 432 4507

www.sha.co.za

The Pavilion,The Wanderers Office Park,

52 Corlett Drive, Illovo, 2196P O Box 55347, Northlands, 2116

Co. Reg. No.: 1985/000368/07VAT No.: 4310103082

Stalker Hutchison Admiral (Pty) Ltd is an authorised financial services provider (FSP 2167)SHA is a wholly owned subsidiary of Santam Limited. Santam is a level 3 BBBEE company

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1. Details of Proposed Insured 1.1 Please provide the following details:-

Insured / Practice Name(Please attach details of all subsidiary companies)

Postal address

Physical address

Contact Person

Tel No. Fax No.

E-mail address Website address

Co. Reg. No. VAT Reg. No.

Present Legal Constitution

Sole Practitioner Partnership Incorporated Co. Limited Co. Closed Corp.

Date of commencement of Practice

As currently constituted

As initially established

1.2 Are any branches of the Proposed Insured located outside of South Africa? Yes No If yes, please provide full details:

1.3 Names and Qualifications of Principals / Partners / Directors / Members as applicable.

Name Qualifications Membership of a Professional Society

How long practical experience in IT

How long Principal in this Practice

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1.4 Staff complementTotal Number of:

Partners / Principals / Directors

Software Design / System Analysts

Quality Assurance

Computer Equipment Operatiors / Data Handling Staff

Sales of Hardware / Software

All other

Total

1.5 Is the Practice or any of the Principals / Directors / Partners connected or associated (financially or otherwise) with any other firm, Company or Organisation? Yes No

If yes, please provide full details:

1.6 During the past 5 years, has:-a) the name of the Firm been changed? Yes No

b) any business been purchased or any merger or consolidation taken place? Yes No

If yes to either, please provide / attach full details:

2. Detailed Business Description:Please provide full details of all activities involved in:(if engaged in multiple disciplines, please provide a percentage split – total must add up to 100%)

3. Business conducted outside South Africa.3.1 Do you or your firm do any business for your clients in the North America or any other countries /

states governed by their laws? Yes No

If Yes, please provide the following details:-a) What percentage of your fees are attributable to these activities?

b) Do you have physical offices in these areas? Yes No If yes:-i) Under who’s Management and Control are these offices?

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ii) Is there any foreign shareholding in these offices and if so what percentage?

Yes / No Percentage %

iii) Do you give any advice relating to the Laws of these Countries? Yes No (if yes provide full details)

3.2 Does the company or any partner, Director, etc. own any assets in the North America? Yes No If yes, please provide full details:

4. 4.1 Approximate percentage of estimated gross income accruing from various activitiesActivity Total Local Foreign

General Consultancy % % %

Systems and/or programme design % % %

Data Processing and/or Communications % % %

Sale of Software packages – programme code modified % % %Sale of Hardware % % %

Sale of Software packages – no programme modification % % %Other (Please specify principal categories) % % %

100%

4.2 Do you design Computer Software packages? Yes No

4.3 a) Do you install Computer Hardware? Yes No b) Do you install Computer Hardware on behalf of another firm as a contractor? Yes No

If yes to any of the above, please submit a copy of the Contract Documents

4.4 If 4.3 (a) & (b) is not applicable, do you design, manufacture and assemble the units yourselves? Yes No


4.5 How many staff, other than Principals, have the authority to quote prices for services performed by the Firm? Yes No

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4.6 Approximate percentage of estimated gross income accruing from various activitiesActivity SA Foreign If Foreign, please state which Country

Government % %

Finance Houses % %Commercial Firms % %Industrial Firms % %Other (Please specify) % %

4.7 Is any of the work subject to the legal jurisdiction of foreign courts? Yes No If yes, please provide the following details:-

Country Client Type of Contract Approximate completion date

4.8 Are any changes expected in the next 12 months? Yes No If yes, please provide full details:

4.9 Have you or will you make any commitments as to sales volume or sales value with any of your suppliers? Yes No

If yes, please specify the amount as a portion of your income for the past 12 months? %

4.10 What portion of Gross Income under 4.1 is derived from the application of computers to industrial processor engineering or architectural design? (Other than accountancy, production or stock control) %

Please give brief details of such work:-

4.11 Do you have access to standby equipment following breakdown or failure of damage to computers or ancillary equipment used by the Firm? Yes No If yes, please state what arrangements are made:

4.12 Do you ensure that duplicate computer system records are:-a) maintained by yourselves or your clients? Yes No b) kept separately from the original records? Yes No If yes, please state what arrangements are made:

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4.13 Give a brief description of typical projects or assignments undertaken by the Firm during the past 3 years.

4.14 Have you ever been involved in the supply, installation or maintenance of or consulting of any systems (including software) in which the year is represented by a 2 character field? Yes No

If yes, please provide the following details relating to millennium date change compliance issues:

a) What action and/or advice have you taken to audit your past contracts?

b) How are you dealing with contracts in progress that is not millennium compliant?

c) What methods will you adopt for future contracts, to ensure that your client negotiations and contract terms address the millennium compliance issue?

5. This Insurance EXCLUDES claims arising from specific contractual liability which goes beyond the provision or use of reasonable care and skill.

5.1 Do you, or will you undertake specific contractual liabilities which go beyond the provision or use of reasonable skill and care? Yes No

5.2 If yes and cover is required for such specific contractual liability:-

a) What portion of Gross Income is applicable hereto? %

b) Submit a copy of each form of contract or other documentation involved.

c) Give details of any other circumstances by which such liability may be undertaken:-

6. Claims experience6.1 Have any claims ever been made against the proposed Insured / Partners / Directors / members or

Employees for the type of cover for which you are now applying, whether in terms of this Proposal or any other Proposal / Policy for the same type of cover? Yes No

If yes, please provide / attach full details:

6.2 After enquiry, are any of the Proposed Insured / Partners / Directors / Members or Employees aware of any circumstances which would be covered under a policy of this type, that may result in any claims or any possible claims being made against them? Yes No

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If yes, please provide / attach full details:

7. Details of Insurance7.1 Are you at present or have you in the past been insured for Professional Indemnity? Yes No

If yes, please provide the following details and attach a copy of the Policy (please note the details of all policies if there is more than one in place):

Name of Broker:

Name of Insurer:

Date cover expires/d:

Expiry of “Run-off” cover (if any):

Limit of Indemnity:

Deductible / Excess applicable:

Premium:

7.2 For the type of Insurance now being proposed, has any Insurer ever :a) declined a Proposal or renewal for this Practice or any Partner / Principal? Yes No b) required an increased premium or imposed special terms? Yes No c) cancelled an Insurance? Yes No


7.3 Do you require cover in respect of any liability incurred but not discovered prior to the effecting of this insurance at a single premium to be negotiated (Retroactive cover)? Yes No

8. Total Gross Income (as at the company’s financial year end)8.1 What is the date of the Company’s financial year-end:

8.2 Please give the audited fees for the last 5 completed financial years (which must include contingency fees):

Year End Fees Year End Fees

R R

R R

REstimate for next 12 months R

9. Quotations requiredKindly advise what limits you would like terms for:-

Limit any one Period of Insurance. Deductibles

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R R

R R

R R(Note: Limit any one period of insurance is inclusive of costs and expenses)

10. ADDITIONAL COVER OPTIONS

10.1 GROUP PERSONAL ACCIDENTSHORT TERM INSURANCE EMPLOYEE BENEFITSWe can insure your employees against loss of income, Death and Permanent Disability if they suffer bodily injury in a motor vehicle accident, sports injury, injury on duty, assault, animal bite etc. This cover is provided on a full 24 hour basis, so your employees will be covered whilst on duty and whilst off duty.

Most companies offer 30 days sick leave in a 3 year cycle, so if an employee is injured and is off work for 3 months, this can be an unbudgeted expense to the business or an unbudgeted expense to the employee’s family,

The product also provides assistance to companies when an employee is injured on duty and need to submit a COID (Workman’s Compensation) claim. This can usually take a number of months to finalise and can affect cash flow in a business. We will also assist companies with Hospital guarantees when an employee is injured on duty.

We have provided a few Quotation Options below for your consideration:

BENEFIT OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5

BASIS OF COVER 24 Hour

Accidental Death R 100,000 R 250,000 R 500,000 R 500,000 R 1,000,000

Permanent Disability R 100,000 R 250,000 R 500,000 R 500,000 R 1,000,000

TTD / Income Protection (Accident Only)

Actual earnings per week (maximum)

R 2,000 R 4,000 R 5,000 R 8,000 R 10,000

payable for a maximum of 52 weeks

7 day excess applies

Medical ExpensesR 10,000 R 10,000 R 25,000 R 50,000 R 50,000

R500 excess per claim applies

PREMIUM PER MONTH PER EMPLOYEE R 25.00 R 50.00 R 90.00 R 110.00 R 180.00

POLICY STRUCTURE: (Multiple Categories have been catered for where an Insured elects to place Employees on varying Benefit Options. The Total Premium per Month will be the Number of Insured Persons for the specific Category, multiplied by the Premium per Month for the specific Option selected)

CATEGORY A CATEGORY B CATEGORY C

Number of Insured Persons

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If not All Employees, please specify DesignationsOption Selected

TOTAL PREMIUM PER MONTH R R R

OPTIONAL ADDITIONAL COVER(Please indicate whether you want a quote) TTD / Income Protection can be extended to include Serious Illness – please refer to SHA for

amended premium confirmation, subject to All Employees being covered. Please note the following : Yes o Only a first time positive diagnosis, made within the Policy period, will applyo A 30 day excess for the Serious Illness component applieso Maximum age for Serious Illness is age 60

Bereavement (an All Causes Death benefit) can be included under the Policy – please refer to SHA for amended premium confirmation, subject to All Employees being covered Yes

Please refer the following Business Risks to SHA upfront, for confirmation of any additional Risk Rating that may be applied (where applicable) Yes o Underground Miningo Oil Rigso Armed Guards

The following Automatic Extensions will be applied to the Policy at inception, at no additional cost:1. Abduction / Hi-jacking / Kidnapping – maximum R500 0002. Accident Expert (COID & RAF Claims Assistance)3. Active Service – R500 000 per person, R1 500 000 per event4. Additional Death Benefit – R15 0005. Alcohol Related Motor Vehicle Accidents – 20% of the Death Benefit, subject to a maximum of

R500,000 6. Childcare – R300 per day, annual limit R10 0007. Claims preparation costs – maximum R50 0008. Crime – 5% up to a maximum of R25 0009. Disappearance – Death Benefit10. Emergency Transportation / Rescue Costs – maximum R100 00011. Family / Servants Medical Expenses – maximum R50 00012. Flying Risks – max R500 00013. HIV Assist including ARV’s – Actual Cost14. HIV Lump Sum Benefit – R500 00015. Hospital Confinement – R2 000 per day, maximum 14 days16. Life support – 3 Consecutive days17. Life support equipment – R100 00018. Mobility – maximum R150 00019. Passive war (Excluding war between major powers)20. Quadriplegia – 20% of PTD benefit, maximum R75 00021. Rehabilitation – maximum R100 00022. Relocation – maximum R40 00023. Repatriation – maximum R50 00024. Seat belt – 10% of Death benefit, maximum R50 00025. Temporary Drivers – R2 000 per week, annual limit R10 00026. Trauma Counselling – R1 000 per visit, annual limit R25 000

10.2 ON THE SPOT DIRECTORS AND OFFICERS COVERPlease Note

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1. Answer ALL questions fully (please continue on a separate sheet of paper if there is insufficient space)

2. This form may be used for new applications or renewals. In the case of renewals, the Underwriters MUST receive completed, signed and dated proposal form and acceptance of renewal terms prior to renewal date, failing which, no cover exists after said date.

Current Insurer:

Limit:

Retro-active date:

Has the company or any of its Directors ever been: Yes No

- Involved in any wilful breach of trust or wilful misconduct proceedings? Yes No

- ineligible or disqualified from holding a fiduciary position? Yes No

- found to have exceeded their authority? Yes No

- involved in any employment related dispute? Yes No

Does the Company’s annual turnover exceed R100m? Yes No

Is the Company’s total assets more than R200m? Yes No

Is the Company a Financial Institution, Airline or State Owned Company? Yes No

Is the Company involved in Pharmaceutical or Mining activities? Yes No

Is the company listed on any stock exchange? Yes No

Is the Company is running at a Loss? Yes No

Does the Company’s Liabilities exceed its Assets? Yes No

Is the Company in a position of Negative Equity? Yes No

Have any claims, insured or not, ever been made, or do you anticipate any claims being made, against any director or officer? Yes No

Has any D & O policy ever been cancelled or not renewed by any insurer or are the any other material facts not yet disclosed? Yes No

If you answered “Yes” to any of the above questions please elaborate on the reason why in writing. SHA will gladly review the risk and respond. Please still indicate as to the option required.

1. Select the Limit of Indemnity you require and the Asset Value of the Company.

LimitPremium for Assets<R50m between R50m between R75m >R150m but not

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and R75m and R150m exceeding R200mR 750,000 R738.28 R984.38 R1 406.25 R1 562.50 R 1,000,000 R885.94 R1 181.25 R1 687.50 R1 875.00 R 1,500,000 R1 004.06 R1 338.75 R1 912.50 R2 125.00 R 2,000,000 R1 092.66 R1 456.88 R2 081.25 R2 312.50 R 2,500,000 R1 181.25 R1 575.00 R2 250.00 R2 500.00 R 3,000,000 R1 476.56 R1 968.75 R2 812.50 R3 125.00 R 4,000,000 R2 008.13 R2 677.50 R3 825.00 R4 250.00 R 5,000,000 R2 362.50 R3 150.00 R4 500.00 R5 000.00 R 6,000,000 R2 646.00 R3 528.00 R5 040.00 R5 600.00 R 7,000,000 R2 835.00 R3 780.00 R5 400.00 R6 000.00 R 7,500,000 R2 953.13 R3 937.50 R5 625.00 R6 250.00 R 8,000,000 R3 012.19 R4 016.25 R5 737.50 R6 375.00 R 8,500,000 R3 071.25 R4 095.00 R5 850.00 R6 500.00 R 9,000,000 R3 277.97 R4 370.63 R6 243.75 R6 937.50 R 9,500,000 R3 307.50 R4 410.00 R6 300.00 R7 000.00 R 10,000,000 R3 543.75 R4 725.00 R6 750.00 R7 500.00 R 12,500,000 R4 252.50 R5 670.00 R8 100.00 R9 000.00 R 15,000,000 R4 784.06 R6 378.75 R9 112.50 R10 125.00

Declaration: 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 effected thereon. I/we undertake to inform underwriters of any material alteration to these facts occurring before the

completion of the contract.

Signed on behalf of Insured Full name

Position held at Insured Date