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Supplementary Financial Services Questionnaire (Please complete, sign and return) Should you have insufficient space to answer any questions, please continue on your own HEADED notepaper LLP 036a - Jun 12 Please note that this questionnaire forms part of your proposal for professional indemnity insurance and you are reminded of the importance of the notes and declaration on the proposal, which also applies to this questionnaire.

Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

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Page 1: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

Supplementary Financial Services Questionnaire

(Please complete, sign and return)

Should you have insufficient space to answer any questions, please continue on your own HEADED notepaper

LLP 036a - Jun 12

Please note that this questionnaire forms part of your proposal for professional indemnity insurance and you are reminded of the importance of the notes and declaration on the proposal, which also applies to this questionnaire.

initiator:[email protected];wfState:distributed;wfType:email;workflowId:1dae497613da914a884e6e1283808f96
Page 2: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

Important note regarding the completion of this proposal form.

1. Disclosure

Any “material fact” must be disclosed to insurers - A “material fact” is any information which may influence the judgement of a prudent insurer in deciding whether to accept the risk and if so, on what terms.

Any “material change” must be disclosed to insurers. - A “material change” is any material fact which arises on renewal or during the currency of the policy that has not previously been disclosed as a material fact. Examples of material changes to material facts include:

• Fraud on the part of any of the Partners and Employees

• A change in the composition of the firm's practice

• Mergers and Acquisitions with other firms

• Conversion to a Limited Liability Partnership

If you are unsure whether a fact or change is material or not, you should disclose it. Failure to provide all “material facts” and/or notify all “material changes” may cause the contract of insurance to be void from inception i.e. your insurers will return the premium and there will be no cover for any claims made under the policy. 2. Presentation

This proposal form must be completed by an authorised individual or principal of the firm.

All questions must be answered.

If there is insufficient space to provide answers, additional information should be provided on the firm's headed paper.

Where available brochures, standard contract conditions, agreements and letters of appointment should be provided.

Failure to present insurers with information in an appropriate manner may adversely influence the ability of insurers to offer terms. 3. Guidance

If in doubt as to the meaning of any question contained within this proposal form or the issues raised in (1)or (2) above, please contact an account executive at Lockton.

LLP 036a - Jun 12

Affinity A division of Lockton Companies LLP Authorised and regulated by the Financial Services Authority A Lloyd's Broker www.lockton.com

Page 3: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

Should you have insufficient space to answer any questions, please continue on your own HEADED notepaper.

1.

Title of Practice:

Yes Noa) Do you presently carry out any regulated activities, as defined in the Financial Services and Markets Act 2000, or act as an introducer in respect of such regulated activities?(Other than in connection with General Insurance Products)

Yes Nob) If 'NO', have you at any time in the past carried out any regulated activities, as defined in the Financial Services and Markets Act 2000, or acted as an introducer in respect of such regulated activities? (Other than in connection with General Insurance Products)

c) If you have answered YES, to Question 1b) please advise:

i) The date you ceased to conduct such business.

ii) Reason for ceasing to conduct such business

Yes Noiii) Did you transfer the liability for such business to an independent third party at cessation date? (If 'YES', please enclose documentary evidence of the transfer of liability)

2. Yes NoHave you purchased/acquired any other firm, company, or book of business, where you have assumed any liability for any regulated activities, as defined in the Financial Services and Markets Act 2000, carried out prior to the acquisition date? (Other than in connection with General Insurance Products).

If you have answered `NO' to questions 1a), b) and 2, there is no need to answer any further questions, please now sign and date the declaration. Otherwise complete questions 3 to 10.

3. Please list on your HEADED notepaper, all principals, Employees and Consultants entitled to undertake Financial Services Authority (FSA) work including their qualifications.

Last Financial year when FSA work was carried out ending:

4. a) Please state total fees derived from financial advice that was/is directly regulated by the FSA:

£

Current Financial year ending: £

b) Please specify the percentage of this income derived from the following:

Year end (dd/mm/yyyy):

%%

%%

%%

%%

Last Financial year when FSA work was

carried out Current Financial

year

Investment in Unit Trusts or Investment Trusts

Investment in Listed/Unlisted Securities

Offshore including Channel Islands and Isle of Man

UK

Investment in Insurance Bonds

Offshore including Channel Islands and Isle of Man

UK

%%

%%

%%

UK

Investment in Commodities

Offshore including Channel Islands and Isle of Man

Page 4: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

%%

%%

%%

%%

%%

Endowments including Mortgage Endowments

Home Income Plans/Equity Release Schemes

Corporate Finance

Life Assurance Products including whole life plans

Pensions and Free-standing AVC's

%%

TOTAL

Other (please give full details)

c) Do you manage or have you managed any discretionary portfolios on behalf of any client? Yes No

If 'YES', please provide a detailed explanation on a separate sheet of HEADED notepaper

d) On what categories of investment business are you or were you authorised by the FSA to provide advice?

e) Has your firm ever been the subject of a complaint made to the Financial Ombudsman Service or any equivalent professional organisation?

Yes No

If 'YES', please provide a detailed explanation on a separate sheet of HEADED notepaper.

5. Please confirm whether you are or were ever:

a) directly regulated by the Financial Services Authority. Yes No

b) regulated or authorised by any other professional body. Yes No

If 'YES', to 5b) please provide details of the professional body.

6. Do you, or have you at any time operated:

a) a Financial Services Company? Yes No

b) a Financial Services Division? Yes No

c) with someone specifically employed to provide Financial Services? Yes No

Commission/brokerage/fees

£

£

£2002

2003

2004

If you have answered 'YES', to 6a), b), or c) please provide the total amount of commission/brokerage/fees received:

7.

£

£

£2005

2006

2007

Commission/brokerage/fees

£

£

£2008

2009

2010

£

£

£2011

2012

Est £Total

Investment in Bonds

%%

%%

Investment in Tangibles (eg. Fine art)

%%

%%

Split Capital Investment Trusts

Institutional Fund Management

100 % 100 %

Page 5: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

a) In respect to Question 1a) and b) please advise in which capacity you act/acted. (If more than one area applies please provide approximate percentage split):

8.

%

%

%

%Yes No

Yes No

Yes No

Yes No

iii) Execution only.

ii) Introductory Agent only.

i) Financial Advisor.

iv) Tied Agent or Appointed Representative.

b) If you have answered 'YES', to Question 8a) ii) please advise:

i) Is there a formal agreement in place where the third party used assumes liability for the work undertaken? (If 'YES', please enclose a copy of the agreement).

Yes No

ii) Do or did you provide any advice to your client while acting as an Introducer, other than introduction of the Third Party?

Yes No

c) If you have answered 'YES', to Question 8b) ii) please advise full details of the advice given:

Have you at any time acted as an introducer, advised on, or sold any:9.

a) i) Split Capital Investments (including Split Capital Closed End Funds) or Zero Dividend Preference Shares? Yes No

ii) Unit Trusts where the portfolio composition consists of a Split Capital Closed End Fund or Zero Dividend Preference Share?

Yes No

If you have answered 'YES', to questions 9 a)i) or ii) you must complete Appendix 1 to this form.

b) Free-Standing Additional Voluntary Contributions (FSAVC's)? Yes No

If you have answered 'YES', to 9b) please advise:

iv) Number of cases where compensation is due or paid.

iii) Total number of cases reviewed (as stipulated by FSA).

£ ii) What is the average contribution in respect of these cases?

i) Total number of cases.

vii) Number of cases where the review is incomplete.

vi) Number of cases where no compensation due.

£ v) What is the average compensation for these cases?

c) Endowment policies (including low cost or low start policies) linked to mortgages? Yes No

If 'YES', you must complete Appendix 2 to this form and advise the following:

iv) Were assumed growth rates in line with the regulator's guidelines?

iii) What proportion of endowments were written with the maturity date beyond the retirement date of the individual?

ii) Were written records always kept including `fact finds' and `reasons why' letters or equivalent?

i) Which product providers were used?

v) Has the Firm received any responses to the `red letters' issued by the life companies?

Yes No

Yes No

Yes No

vi) Has the Firm been a tied agent or appointed representative?

vii) Has it been the Firm's practice to advise intending investors (and to document on file) that:

Yes No

a) an endowment cannot be guaranteed to pay off any mortgage loan at maturity?

b) other forms of mortgage repayments are available which meet the client's needs?

Yes No

Yes No

c) that an endowment policy involves an investment risk? Yes No

viii) Has the Firm complied with all relevant regulatory requirements in respect of each sale? Yes No

ix) What is the earliest date of the endowment files that you are currently storing in closed files?

Page 6: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

d) i) Pension Transfers/Opt-outs/Non-joiners between April 1988 and June 1994? Yes No

ii) Pension Transfers/Opt-outs/Non-joiners since July 1994? Yes No

If 'YES', please advise.

iii) Has the Pension Review been completed and compliance signed off by an independent third party for these activities undertaken prior to July 1994?

Yes No

If 'NO', please provide full details on a separate sheet of HEADED notepaper.

iv) Total number of cases where compensation was due/paid

£ v) Average compensation due/paid

£ vi) Total amount of compensation due/paid

e) Pensions, Annuities, Income Drawdown or Equity Release, other than under 9d) above? Yes No

If 'YES', please advise

i) Number of cases.

£ ii) Gross fees received.

Are you aware of any compliance problems with your Practice in relation to regulated activities as defined in the Financial Services and Markets Act 2000?

10.Yes No

If 'YES', please provide full details on a separate sheet of HEADED notepaper.

Data Protection

By signing this proposal form you consent to Lockton Companies LLP using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third-party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. In the course of performing our obligation to you, this information may be disclosed to agents and service providers appointed by us and insurers (which includes their re-insurers, legal advisers, loss adjustors or agents). Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and, where appropriate, in compliance with the relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.

From time to time, we may disclose personal information (other than sensitive personal data) to other Lockton Companies. We or they may use that information to advise you of our services which may be of interest to you.

If you would prefer not to receive information, please tick this box Proposer's Declaration

I/We declare that the above statements and particulars are true, full enquiry having been made, and I/We have not omitted, suppressed or mis-stated any material facts which may be relevant to insurer's consideration of this proposal form and undertake to inform the Insurer of any change to any material fact that occurs prior to the point at which the insurance contract has been agreed.

I/We understand that the information I/We provide will be used in deciding the price charged by the Insurer for the risk and whether the Insurer will accept the application and the terms of any policy provided.

I/We hereby consent to the use and disclosure of information including personal data for the purposes of and as set out in the above paragraph entitled “Data Protection”.

Please note, if you wish to submit your form via email, an indication of terms and conditions may be provided on the basis of this proposal questionnaire. An original signature is required before a contract of insurance can be made. Encrypted signatures are not acceptable.

Signing this form does not bind the Practice to complete the insurance. We recommend that you keep a record of all information supplied to us, including copies of letters and this proposal form, for the purpose of entering into this contract.

Print Name:

Date:

On Behalf of :

Signature:

(an authorised individual/principal)

Print Name:

Date:

On Behalf of :

Signature:

(an authorised individual/principal)

Page 7: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

APPENDIX 1

£

£ £

£

Maximum ValueAverage ValueNumber

ii) Unit Trusts where the portfolio composition consists of a Split Capital Closed End Fund or Zero Dividend Preference Shares

i) Split Capital Closed End Fund or Zero Dividend Preference Shares

Loss as % of Total

InvestmentName of Investor Name of Fund/Provider

Amount Invested* % Total ** Current

Value (£) * Loss (£) *Gain/Loss on all other Investments

(£) ***

SPLIT CAPITAL INVESTMENT TRUST/ZERO DIVIDENDS PREFERENCE SHARES INFORMATION (including unit Trusts holding 33.33% or more of Split Capital Investment Trusts)

* Re. Split capital Investment or Zero Dividend Preference Share Investment ** What percentage is the Split Capital Investment or the Zero Dividend Preference Share Investment of the total investment? *** i.e. Everything else other than Split Capital Investment or the Zero Dividend Preference Share Investment

APPENDIX 2

£

£ £

£

Maximum ValueAverage ValueNumber

ii) 1992 - 1994

i) 1988 - 1991

£

£ £

£

iv) 2000 - present

iii) 1995 - 1999

Page 8: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal

APPENDIX 3Additional space if required

Have you signed and dated the proposal form?

Page 9: Supplementary Financial Services Questionnaire Services Fo… · Supplementary Financial Services Questionnaire ... Please note that this questionnaire forms part of your proposal