Financial services questionnaire

All fields marked * require completion.

Your details

If 'Yes', please advise the date you ceased to conduct the regulated activities and the reasons for doing so:

  

If you have answered 'No', to all of the above questions, there is no need to answer any further questions.

Please now submit this form.

Otherwise please complete the remaining questions.

General information

If 'Yes', please provide the name of the professional body

Have you at any time operated:

Your fee income

Provide details of your gross income (commission / brokerage / fees) received from regulated activities in the last six financial years and your estimated income for the forthcoming year:

Your business activities

Please advise in which capacity you acted. (If more than one area applies, please provide an approximate percentage split):

If 'Yes', please advise

Split capital closed end fund or zero dividend preference shares

Unit trusts where the portfolio composition consists of a split capital closed end fund or zero dividend preference share:

If 'Yes', please advise:

1988-1994

1995-1998

1999-present

If 'Yes', please advise:

If 'Yes', please advise:

If 'Yes', please advise:

Attach additional information

If you would like to attach more information, please upload your file here.

Disclosure of Material Facts

It is essential that every Proposer or Insured when seeking a quotation, taking out or renewing an insurance, reveals to the prospective Insurers any material facts or information (including any material circumstances or change in circumstance) which might influence the judgement of Insurers in fixing the premium or in determining whether they will accept the risk. Failure to do so may render the contract of insurance voidable from inception at the option of the Insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, seek our advice.

Declaration

By submitting this form, I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or mis-stated any material facts and undertake to inform the Insurer of any change to any material fact. I understand that the information I provide will be used in deciding the price charged by the Insurer for the risk and whether the Insurer will accept the application. I further agree that this declaration, together with any other information provided shall be the basis of any contract between me and the Insurer.