APIGIS – Architects PI Proposal Form Architects PI Proposal Form Business / Practice DetailsPractice / Business / Insured Name:* SACAP Registration Number:* Are you a member of SAIA?* YES NO If YES, please provide your SAIA membership number: Are you a member of a Regional Association?* YES NO If YES, please provide membership number: NB: If you are a member of SAIA or Regional Institute you would qualify for an exclusive APIGIS quotation. ‘APIGIS’ is the ‘Architects Professional Indemnity Group Insurance Scheme’ and has added benefits. Contact Annie Godfrey at APIGIS for more information on firstname.lastname@example.org or 0713633617VAT Registration number:* Physical Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Postal Address*Tel Number:*Fax Number:Location of Branch Offices: Contact Person Email:* Contact Person Tel Number:*Contact Person Cell Number:*Date of Commencement of Practice as currently constituted:* DD slash MM slash YYYY Date of Commencement of Practice as initially established:* DD slash MM slash YYYY Names and qualifications of Principles, Partners or Directors:*NameQualificationsDate Qualified Staff complement (total number of)*Partner / Principle / DirectorsArchitects (Qualified)Senior Technologists (Qualified)Technologists (Qualified)Draftsmen (Qualified)Candidate StaffAll Other StaffTotal ComplimentPolicy Holder Protection Data (Compulsory)Is the Insured’s annual Turnover or Asset Value LESS than R 2,000,000?* Yes No What is the Present Legal Constitution of the Insured Company?* Sole Practitioner Partnership Incorporated Co. Limited Co. Closed Corp. Kindly reflect the Percentage of Total Gross Fee Income earned in respect of the discipline/s in which the Business/Practice is engaged in:Architecture Project Management (Kindly complete Annexure A below) Other Activities (Please specify) "Annexure A"Please give the approximate percentage applicable to Project management as a percentage of the total work that you have carried out during the past 12 months. Please note that all questions must be answered and should total 100%.Feasibility Studies, Reports, Surveys, etc (where applicant is involved in actual design work) Bridges and/or Tunnels Dams Mines Harbors or Jetties Sewerage Schemes Foundations and Underpinning Soil Testing Water Schemes Nuclear or Atomic Projects Heating Ventilating and Air Conditioning Chemical, Petro-chemicals and Refineries Housing Schemes Buildings Schools, Hospitals and Municipal Buildings Industrial Systems Buildings Mechanical Plant and Bulk Handling Equipment (including silos, etc) Other work including any specialist activities not shown above* Date of Financial Year End Day Month Year Please provide your Gross Income Earned as at your last three financial year ends.Previous YearPeriod FromPeriod ToSA Work OnlyAfrica ProjectsOther CountriesPast YearPeriod FromPeriod ToSA Work OnlyAfrica ProjectsOther CountriesCurrent YearPeriod FromPeriod ToSA Work OnlyAfrica ProjectsOther CountriesEstimatedPeriod FromPeriod ToSA Work OnlyAfrica ProjectsOther CountriesKindly provide a list of countries for the income earned outside of South Africa Has this Practice or any Partner/Principal/Director or Employee been appointed as Principal Agent? YES NO Has this Practice or any Partner/Principal/Director or Employee been appointed as Project Manager? YES NO Does the Practice or any Partner/Principal/Director have any association with or financial interest in any other Practice/Company Organisation? YES NO Does the Practice or any Partner/Principal/Director engage with/have a financial interest in/have an association with any other practice or person in a Single Project Partnership? YES NO Is the Practice or any Partner/Principal/Director a member of a Consortium or Group Practice? YES NO If YES to any of the above, kindly provide details.Disclose all claims of professional negligence, errors or omissions made against the Practice or any of the present or past Partners/Principals/Directors and/or Employees, whether notifies to Insurers or not within the past 3 years. (Attach page if needed)Upload a file here if needed Drop files here or Select files Accepted file types: pdf, Max. file size: 52 MB. After consultation with all of the Partners/Principals/Directors and Employees of the Practice, are you aware of any circumstances that may give rise to a claim for professional negligence, errors or omissions? YES NO If YES, provide details. (Attach page if needed)Upload a file here if needed Drop files here or Select files Accepted file types: pdf, Max. file size: 52 MB. Has this practice been previously insured for Professional Indemnity? YES NO If YES, please state:Name of InsurersIndemnity LimitExpiry DateExcess / DeductibleKindly advise the Limit of Indemnity you require:* Has any insurer ever declined proposal or renewal for this Practice or any Partner/Principal? YES NO Has any insurer ever required an increased premium or imposed special terms? YES NO Has any insurer ever cancelled an Insurance Contract? YES NO If YES, please state:Declaration* I/We hereby declare that the statements and particulars in this application are true and complete. I/We agree that this Proposal and Declaration be the basis of the Contract between me/us and the Insurers.CommentsThis field is for validation purposes and should be left unchanged.