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Proposers Details
Surname	:
First Name	:
Company Name	:
Telephone No. (Work)	:
Telephone No. (Cell)	:
E-mail Address	:
General Details
This insurance is dependent upon the, correct and complete information being given.
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:
Income / Turnover
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 Private client (employed income only up to R 1 000 000) Private client (employed income in excess of R 1 000 000) Business client with turnover of less than R 1 000 000 Business client with turnover of R 1 000 001 to R 5 000 000 Business client with turnover of R 5 000 001 to R 10 000 000 Business client with turnover of R 10 000 001 to R 15 000 000 Business client with turnover of R 15 000 001 to R 25 000 000 Business client with turnover of R 25 000 001 to R 50 000 000 Business client with turnover of R 50 000 001 to R 100 000 000
How did you hear about Qdos?
How would you like to be contacted : E-mail Telephone

If you are uncertain of any of the details you are required to fill in, please do not hesitate to contact us for further information or send an email to enquiries@qdosconsulting.co.za