DIRECTORS & OFFICERS LIABILITY PROPOSAL/KYC FORM

IMPORTANT

An Insurance Agent who assists an applicant to complete an application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act 2003.Please answer ALL questions in full. Use CAPITAL LETTERS.

DETAILS OF PROPOSER

Name of Proposer:

Address of Proposer (Not P.O. Box):

Telephone Number:

Company Website:

Email Address:

DETAILS OF PROPOSER

Date of Registration:

Incorporation No.:

Nature of Business:

Name of Bankers:

Address of Bankers:

Name of Auditor:

Address of Auditor:

NAMES/ADDRESS OF COMPANY DIRECTORS:

Name:

Address:

Name:

Address:

Name:

Address:

OTHER DETAILS:

Country of Registration:

Number of Years in Operation:

Company Subsidiaries:

Is The Company: Private Public Listed on Foreign Stock Exchanges

During The Last Five Years Has:

The Name of the Parent Company Changed?

Yes No

Any Acquisition or Merger Taken Place?

Yes No

Any Subsidiary Company been Sold or Ceased Trading?

Yes No

The Capital Structure of the Parent Company Changed?

Yes No

If Yes to any of the above four (4) questions, Please Give Details:

Is the Company Involved in or Considering any Acquisition, Tender Offer or Merger?

Yes No

Is the Company Aware of any Proposal Relating to its Acquisition by Another Company?

Yes No

Is the Company Intending a New Public Offering of Securities Within the Next Year?

Yes No

Is the Company Considering Extending Operations to the RSA, UK, USA, or Elsewhere?

Yes No

Please Specify Country, Stock Exchange and Type of Listing? e.g. ADR (and Level), Direct Listing etc.):

Listed on the Unlisted Securities Market?

Yes No

Traded in any Other Way?

Yes No

If Yes, to any of the above two (2) questions, Please Specify:

Please List

Total No. of Shareholders:

Total No. of Shares Issued:

Total no. of Shares Held by Directors and Officers (both direct and beneficial):

All Holdings Representing 15% or More of the Ordinary Share Capital of the Company Giving the Holder and the Percentage Held by Each:

Holder's Name:

Percentage Held:

Holder's Name:

Percentage Held:

Holder's Name:

Percentage Held:

Holder's Name:

Percentage Held:

Holder's Name:

Percentage Held:

Holder's Name:

Percentage Held:

Please Give Details of any Change to the List of Directors & Officers in the Company's Last Report and Accounts:

Give a Complete List of All Subsidiary Companies Including Country of Registration and Percentage Owned by Parent Company Other Than Those Shown in the Last Report and Accounts:

Subsidiary Company:

Country of Registration:

Percentage Owned by Parent Company:

Subsidiary Company:

Country of Registration:

Percentage Owned by Parent Company:

Subsidiary Company:

Country of Registration:

Percentage Owned by Parent Company:

Does any Management Officer or Employee Hold any Outside Board Position? Yes No

If Yes, is Coverage for Such Position Required? Yes No

Please Give Details if the Above is Yes:

Name of Organization:

Director's Name:

Name of Organization:

Director's Name:

Name of Organization:

Director's Name:

Name of Organization:

Director's Name:

Is Cover Required for Pollution Defense Costs? Yes No

Does the Company or any Director or Officer have Directors & Officers Liability Insurance Currently in Force? Yes No

If Yes, Please State:

Insurer Indemnity Limit:

Expiry Date:

Has the Company Ever had any Insurer Decline a Proposal or Cancel or Refuse to Renew a Directors & Officers Liability Insurance? Yes No

If Yes, Please Give Details:

Has any Director and/or Executive Officer of the Company Resigned or been Replaced in the Past 12 months? Yes No

If Yes, Who and Why?

Has the Company Changed its External Auditing Firm in the Past Five Years? Yes No

If Yes, Why?

Does the Company Have any Plans to Remove or Replace its External Auditor in the Next 12 months? Yes No

If Yes, Why?

Have all Revenue Recognition Practices Been Approved by Your External Auditor? Yes No

If No, Please Provide Details:

Does the Company, any of its Subsidiaries or any of its Directors and/or Officers have any Interests in any Partnerships or Special Purpose Vehicles or Entities? Yes No

If No, Please Provide Details:

Has the Company Ever Restated its Financial Results? Yes No

If No, Please Provide Details:

Does the Company Anticipate Having to Take a Significant One Time Charge to Earnings, or a Restatement of Earnings,
within the Next 12months? Yes No

If Yes, Please Provide Details: (all matters arising are excluded from cover under this policy)

DETAILS OF CLAIMS

Have Claims Ever been Made Against any Past or Present Director or Officer of the Company or Its Subsidiaries? Yes No

If No, Please Provide Details:

Is the Proposer Aware, After Inquiry, of any Circumstance or Incident which may Give Rise to a Claim? Yes No

If No, Please Provide Details:

INDEMNITY LIMIT

Amount of Indemnity Required:

EMPLOYMENT PRACTICES LIABILITY

Do you Require Employment Practices Liability Cover? Yes No

If Yes, Please Complete Questions on the Supplementary Sheet Attached. These Questions Form Part of the Proposal Document.

DECLARATION

I/We, hereby declare that the above particulars and answers are true and complete in every respect, and that no
information has been suppressed or withheld. I/We further declare that if such statements and particulars are in the writing
of any person other than myself/ourselves such person shall be deemed to have been my/our agent for the purpose of filling
the form.

Name of Proposer:

Signature:

Date:

Agent/Company Representative:

PLEASE PROVIDE THE FOLLOWING * Please provide photocopies and also bring along original copies of the documents for confirmation.

A) The Last Two Annual Reports and Accounts for the Company

B) The Last Two Interim Statements (If Applicable)

C) Any Offer Document/Listing Particulars Published in the Last 12 Months

D) Certificate of Incorporation/Registration

E) Memorandum & Article of Association

F) Form CO2

G) Form CO7

H) Copy of authorization to Operate from relevant regulatory bodies.