Proposal Form
   

Print out the Proposal form, complete and email to us at enquiries@qdosconsulting.co.za or fill out the form below and we'll get back to you.

Proposers Details
Surname :
First Name :
ID Number :
Occupation :
Company :
Company Reg Number :
Postal Address :
E-mail Address :
Company VAT No :
Telephone No. (Work) :
Telephone No. (Home) :
Telephone No. (Cell) :
Telephone No. (Fax) :
     
Period of Insurance & Broker Details
Accountant/Auditor/Tax Practioner :
Introduced by :
Premium Payment Method (Please Tick) :
Annual Premium
Monthly Debit Order
Premium Payable R:
     
Debit Order Authority
Name Of Bank :
Branch :
Account Number :
Account Holders Name :
Branch Code :
Type Of Account :

I hereby authorise The Insurer to draw against the above account (or any other institution to which I may transfer my account) the amount necessary for the payment of the monthly premiums and adjustment premiums due to the Insurers in respect of the insurance herein proposed. I agree that in the event of any debit order not being met by my financial institution the policy will be cancelled and of no effect from midnight on the last day of that month for which the Insurer has received premium. (Subject to the period of grace).

Accept Decline
     
Declaration
Accept Decline
     
General Details

This insurance is dependent upon true, correct and complete information being given. All relevant information, whether asked for or not must be disclosed. Use seperate page if required, or leave comments in comment box.

Have you or your business submitted any tax returns after the filing deadline during the past three years?
Yes No
Have you or your business received any enquiry into a tax return or disputed a VAT or PAYE assessment from the South African Revenue Service in the past 2 years?
Yes No
Have you or your business previously applied for tax amnesty from the South African Revenue Service?
Yes No
Have you or your business ever been sequestrated / liquidated or had judgements against them?
Yes No
Do you know of any current reason or circumstance which could give rise to a claim under this policy?
Yes No
If you have answered “yes” to any of the above questions please elaborate below:
     
Premium Pricing (inclusive of VAT)
Premiums are payable based on a scale of gross income for individuals and gross revenue for companies. Kindly indicate your approximate income / gross revenue below:
CATEGORY:
(income, turnover as at last tax year end, company year end)		 Select Gross Annual
Premium		 Gross Monthly
Premium
Private clients (employed income
only up to R 1 000 000)
R 595  
R 55  
Private clients (employed income
in excess of R 1 000 000)
P.O.A.  
P.O.A.  
Business clients with turnover of
less than R 1 000 000
R 1,725  
R 158  
Business clients with turnover of
R 1 000 001 to R 5 000 000
R 2,100  
R 193  
Business clients with turnover of
R 5 000 001 to R 10 000 000
R 2,375  
R 218  
Business clients with turnover of
R 10 000 001 to R 15 000 000
R 2,700  
R 248  
Business clients with turnover of
R 15 000 001 to R 25 000 000
R 4,000  
R 367  
Business clients with turnover of
R 25 000 001 to R 50 000 000
R 5,500  
R 504  
Business clients with turnover of
R 50 000 001 to R 100 000 000
P.O.A.  
P.O.A.  
     
How would you like to be contacted :
E-mail
Phone
Once everything is accepted we will send original docs for signature.
     
   

 
 
 
 

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