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?
If 'No', have you at any time in the past carried out any such regulated activities or acted as an introducer in respect of such regulated activities?
If 'Yes', please advise the date you ceased to conduct the regulated activities and the reasons for doing so:
Have you purchased or acquired any other firm or book of business where you have assumed any liability for any such regulated activities, carried out prior to the acquisition date?
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.
Are you regulated or authorised by any other professional body to carry out any regulated activities?
If 'Yes', please provide the name of the professional body
Have you at any time operated:
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:
Please advise in which capacity you acted. (If more than one area applies, please provide an approximate percentage split):
Have you at any time acted as an introducer of, advised on or sold any split capital closed end fund or zero dividend preference share or any unit trusts where the portfolio composition consists of a split capital closed end fund or zero dividend preference share?
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:
Have you at any time advised on or sold any endowment linked mortgages?
Have you at any time advised on or sold any free-standing additional voluntary contributions? (FSAVC's)?
Have you at any time advised on or sold any pension transfers, opt outs, non-joiners between April 1988 and June 1994?
Have you at any time advised on or sold any other pensions, annuities, income drawdowns or equity release products?
Please give a brief description of any other regulated activity, not specifically declared in this questionnaire or proposal, carried out by you in the last three years:
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 there under. If you have any doubt as to what constitutes a material fact or circumstance, seek our advice.
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.
