Financial Advisers Professional Indemnity Insurance Proposal Form

Financial Advisers Professional Indemnity Insurance Proposal Form IMPORTANT Disclosure of material facts or information It is essential that every Proposer or Insured when seeking a quotation, taking out or renewing an insurance contract, reveals to the prospective Insurers any material facts or information (including any material circumstances or change in circumstances) which might influence the judgement of Insurers in setting the premium and/or the terms and conditions of the insurance contract or in determining whether they will accept the risk. The statements made in this Proposal Form (including any supporting information) will form the Proposer or Insured s representation to Insurers and as such will be the basis of the insurance contract. Failure to disclose material information may render the insurance contract voidable from inception at the option of Insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, seek advice from your insurance intermediary. All claims and circumstances which may give rise to claims must be declared in the Proposal Form. Best practice in terms of notifying claims and circumstances would be for each Partner/Director and senior member of staff to sign a declaration to the effect that he/she has investigated the areas for which he/she is responsible and can confirm that there are no claims or circumstances other than those (if any) contained in the Proposal Form. A proforma declaration is set out in the Declaration section of this Proposal Form and all completed Declarations should be attached. All questions must be answered. If when completing this Proposal Form manually you have insufficient room to answer any question please provide the answer on your headed paper and attach it to this Proposal Form. Please also enclose: a) a copy of your standard contract/terms of engagement. b) samples of your corporate brochure/literature. Page 1 of 20

1. The Practice(s) 1.1. Please provide below the details of the main Practice(s). Name Postcode Main Office Address Website Address Commencement date Last complete financial year / / / / to / / The Practice s Regulator Please also provide, if applicable: the full name(s) of any other Practice(s) currently trading any other trading styles any other addresses from which the Practice(s) conduct business 1.2. Are there any past Practice(s) including predecessors in business for which cover is required for their period of trading? YES NO If YES please complete the table below. Name(s) Period of Trading (please show commencement and cessation date(s)) / / to / / / / to / / 1.3. Please tick the box to confirm that none of the Practice(s) shown in question 1.2. above is/are a Limited Company that has been wound up and/or has no assets. 1.4. In respect of the Practice(s) requiring coverage please provide the following: Names of Directors/Partners/Principals Age Qualifications Experience (if under 5 years practical relevant experience) Page 2 of 20

1.5. In respect of the Practice(s) stated in answer to question 1.1 please advise the number of permanent staff other than Directors/Partners/Principals: a) Employed persons giving advice b) All other employed persons c) Self employed persons 1.6. Has the Practice(s) stated in question 1.1. above been awarded Chartered Financial Planner status YES NO If No, have any employees been awarded Chartered Financial Planner status YES NO If Yes, how many? 1.7. Is cover required for any Appointed Representatives of the Practice(s) stated in question 1.1. above? YES NO If YES, please complete the table below Name (please indicate whether they trade as incorporated business) Date(s) of Appointment Commission(s)/fees for the last complete financial year Geographical Location(s) (please indicate if in the same office as the Principal if applicable) 1.8. Please advise the client / adviser ratio of the Practice(s) : Page 3 of 20

2. The Income of the Practice(s) 2.1. In respect of the Practice(s) for which cover is required, please state for the last complete financial year and the previous two financial years (where applicable) the total gross brokerage/commission/fee income, including income generated by all principals/employees/self-employed persons. a) Total gross income for the last complete financial year: b) Last complete financial year: Total gross brokerage/commission/fee income, UK business including trail commission Overseas business excluding USA/Canada USA/Canada business Year: Year: 2.2. Please estimate for the current and next financial years the total gross brokerage/commission/fee income, including trail income, in respect of the Practice(s) for which cover is required: Current financial year: Total gross brokerage/commission/fee income, UK business including trail commission Overseas business excluding USA/Canada USA/Canada business Next financial year: 2.3. Please provide details of the top 3 product providers in terms of commission income in the last complete financial year: Provider Percentage of total commission income Page 4 of 20

2.4. Please provide details of the top 3 product providers in terms of number of new policies in the last complete financial year: Provider Total number of policies 2.5. In the last complete financial year what of gross income was fee based? Page 5 of 20

3. The Activities of the Practice(s) 3.1. Please provide the percentage of total gross brokerage/commission/fee income, including trail income for the last complete year as disclosed in question 2 derived from the following categories. Please ensure that boxes A to F below add up to 100 A) Pension Sales & Advice A Of the total for A above, please indicate earned from the following categories and the percentage between private and business: i) Personal Pension Plans ii) Self-Invested Personal Pensions iii) Small Self-Administered Schemes iv) Executive Pension Plans v) Alternatively Secured Pensions vi) Income Drawdown / Unsecured Pension / Phased Retirement vii) Pension Unlocking (other than in vi) above) viii) Individual Pension Accounts ix) Annuities x) Defined Benefit Schemes xi) Pension Transfers i) from money purchase schemes ii) from defined benefit schemes xii) Other (please specify) B) Investment Sales & Advice B Of the total for B above, please indicate earned from the following categories and the percentage between private and business: i) Insurance / Investment Bonds a) UK (excluding C.I. and I.O.M.) b) Offshore Page 6 of 20

ii) Unit Trusts / ISAs a) UK (excluding C.I. and I.O.M.) b) Offshore iii) Mortgage Linked Endowments iv) Regular Savings Products (including Endowments not linked to mortgages) v) Structured Products vi) Private clients Portfolio Management (please state whether discretionary or not) vii) Investment vehicles designed/used specifically for tax mitigation reasons, e.g. (and not restricted to) Film Partnerships, EZT s, VCT s, Property Funds, Carbon Trading Partnerships. If any, please state which types of investment are utilised: viii) Other investment vehicles including (and not restricted to) TEPs, viaticals/traded life policies, securities dealing, commodities dealing, investment in tangibles, etc If any, please state which: C) Life Cover and Protection Product Sales & Advice C Of the total for C above, please indicate earned from the following categories and the percentage between private and business: i) Life ( including whole of Life ) ii) Protection ( including PHI and ASU ) iii) Non regulated Term Assurance Page 7 of 20

D ) Mortgages Sales & Advice (any borrowing secured on real property including Equity Release and Home Income Plans) D E) General Insurance Sales and Advice E Of the total for E above, please indicate earned from the following categories and the percentage between private and business: i) Motor ii) Personal Lines iii) Commercial Lines iv) Professional Indemnity v) Marine/Aviation vi) Reinsurance vii) Other ( Please specify) F) Miscellaneous F Of the total for F above, please indicate earned from the following categories and the percentage between private and business: i) IHT / Estate Planning ii) Hedge Funds iii) Back Office, Compliance or Audit Services for Third Parties iv) Other (please specify) Total 100 Page 8 of 20

3.2. With regard to General Insurance business, have the proposing Practice(s)/Firm(s) had any agencies cancelled during the last year? If YES, please advise reason(s) given for cancellation(s): 3.3. In respect of any investment business declared in 3.1. B) above please indicate the number of single premium or annual investments made in the last financial year where the sum invested was: (Please do not include monthly investments.) Number of investments a) less than 10,000 b) equal to or more than 10,000 but less than 25,000 c) equal to or more than 25,000 but less than 100,000 d) equal to or more than 100,000 3.4 In respect of any investment business declared in 3.1. B) vi) please give details of average / largest investment values: Average Largest Page 9 of 20

4. FSA Regulation and Compliance 4.1. During the last 12 months has any Practice(s): a) received notice of a visit from the FSA? b) been the subject of any FSA regulatory control visit or regulatory review? c) attended an FSA Roadshow or conducted a telephone interview with FSA? d) received any warning letters from the FSA? e) been referred to enforcement, fined or suspended by the FSA? If YES to b), c), d) or e) above, please provide copies of the relevant letter(s) or report(s) or any other correspondence with FSA relating to these subjects. 4.2. If advice has been given or other activity been undertaken outside the UK or in the UK for clients domiciled in other jurisdictions by the Practice(s) for which coverage is being sought please answer the following: a) Do you hold an Insurance Mediation Directive (IMD) passport? b) Do you hold a Markets in Financial Instruments Directive (MiFiD) passport? c) Do you hold a domestic authorisation in any EEA State for business which falls outside the remit of any passport? d) the countries applicable outside of the EEA If YES to any of the above please explain why:- 4.3. The following information is required by the FSA to be recorded by regulated firms as Key Performance Indicators. It is also of interest to underwriters in assessing the risk presented by the Practice(s). Please advise: the number of policies Paid Up or lapsed in the last 12 months the number of policies cancelled within cooling off period in the last 12 months the number of recommendations Not Taken Up in the last 12 months the number of policy replacement recommendations made in the last 12 months to discontinue premiums or surrender existing contracts and replace with similar contracts 4.4. Does/Do the Practice(s) gather such Management Information and Key Performance Indicators that evidence its/their service levels to clients? 4.5. Where these indicators show that performance is not to the required standard is/are the Practice(s) able to manage the rectification process? Page 10 of 20

4.6. Please advise the number of full time compliance staff employed (please provide the CV of the Compliance Officer). If no compliance staff are employed, please provide details below of how the compliance function is managed. If a specialist provider is used please provide name and CV of the person assigned to the Practice(s). 4.7 Please provide the location of any individuals providing advice who are not based at the main office address 4.8. Was each individual referred to above the subject of a field compliance audit on their premises in the last 12 months? 4.9 Please indicate the percentage of new business files reviewed by the compliance department in the last 12 months Page 11 of 20

5. Additional Information 5.1.i. Has/Have the Practice(s) received any commission/fees in any of the last 6 years in respect of any of the following products or services: a) Investments in Hedge Funds, collective investment schemes investing in Hedge Funds or any other unregulated collective investment scheme (UCIS)? b) Private Client Portfolio Management services where you have discretion in respect of investment and realisation of funds? c) Self Certified Mortgages / Non Status Mortgages? d) Pension Fund Trustee services? e) Investment in any Traded Life Policy or Viatical Settlements or any collective investment with funds invested in either product? f) Investments in any offshore based product? g) Structured Capital at Risk Products? h) Film Finance Schemes? i) Venture Capital Trusts (VCT)? j) Enterprise Zone Investments? k) Enterprise Investment Schemes (EIS)? l) Deferral Relief Companies? m) Inheritance Tax Planning? n) Sub-Prime Mortgages? o) Payment Protection Insurance? p) Home Income Plans, Equity Release Schemes or Home Reversion Schemes? 5.1.ii. Has/Have the Practice(s) ever dealt directly or indirectly or otherwise provided advice or services in respect of any bank, product provider, financial institution, fund or investment: which is currently or has previously been insolvent, has a known liquidity problem or has otherwise failed (including but not restricted to Lehman Bros)? whose shares, investments or funds have been suspended or frozen to withdrawals (including but not restricted to Arch Cru and Keydata)? which is under investigation by the Police, SFO, FSA SEC or other regulatory authority in relation to allegations of fraud (including but not restricted to Madoff investments)? Page 12 of 20

If YES to any of the above categories in 5.1.i. and/or 5.1.ii. please provide details including numbers, values and the procedures followed, continuing on a separate sheet if necessary. 5.2. Please confirm what percentage of the income declared in answer to Q 2.1. for your last complete financial year relates to all of the business in 5.1.i. above where you have answered YES. 5.3. If any clients have invested in a) above please confirm that the holdings represent less than 10 of the clients portfolio 5.4. If NO, please clarify your approach to clients investing in a) above and confirm the highest concentration you would recommend for any one investment and into UCIS as a whole 5.5. If YES to any of the products listed in h) to m) above has the Inland Revenue indicated that they intend to challenge the tax status of any of the products arranged on behalf of any client? If YES please provide details Page 13 of 20

6. Risk Controls 6.1. Does/Do the Practice(s) have documented compliance policies in place in respect of the sales process which are appropriate for the various areas of its business? If YES, please give FULL details on a separate sheet. 6.2 Does/Do the Practice(s) maintain a Risk Register and have systems of control in place to manage the risks? If YES, please give FULL details on a separate sheet. 6.3. Have all clients with whom the Practice(s) work signed terms of business agreements together with a letter setting out the scope of the Practice(s) services? 6.4. Does/Do the Practice(s) have anti money laundering controls as well as appropriate KYC/client verification controls? 6.5. Does/Do the Practice(s) have systems in place to ensure key dates are controlled and backed up in the event that the client liaison individual is detained from the office? 6.6. Does/Do the Practice(s) have supervisory controls which also extend to all Partners / Directors? 6.7. Are all staff appraised at least once a year and any development issues followed through? 6.8. Does/Do the Practice(s) provide facilities to ensure that all staff can keep up to date with all important news and developments? 6.9. Are all instructions from clients and their requirements evidenced in writing? 6.10. Can all individuals in the Practice(s) access standard risk warnings to include in their letters/reports? 6.11. Where the Practice(s) receive(s) a complaint does/do it/they have the ability to look back into the process to check if there are any weaknesses or training needs evident? 6.12. Does/Do the Practice(s) ensure that only appropriately qualified individuals provide advice in connection with products where specific authorisation is required by FSA? 6.13. For which types of instruction is pre-sale checking authorisation required? Page 14 of 20

6.14. What proportion of post sale activity is reviewed and which (if appropriate) categories receive higher checking rates? 6.15. Where the Practice(s) use/uses business introducers does it/they ensure due diligence is undertaken and it/they have signed terms of business in place? 6.16. Please outline briefly, on your headed paper if necessary, the steps that the Practice(s) take to minimise the risk of fraud by employees or agents of the Practice(s). 6.17. a) Does/do the Practice(s) have a written policy specifying its/their conflicts of interest procedures, which include a cross-check system and back up? b) In the event of a conflict of interest does/do the Practice(s): i) inform the client in writing? ii) advise the client to seek independent advice? iii) continue to act for the client? Page 15 of 20

7. Claims History 7.1. Please confirm after enquiry if there have been any claims made against the Practice(s) or any of the present or past Directors/Partners/Principals in the past 10 years. YES NO If YES please provide FULL details: Date claim made Summary Amount claimed Reserve held (if applicable) Amount paid (if applicable) Date of the advice leading to the claim 7.2. Has/Have the Practice(s) sustained any loss during the past ten years as a result of the fraud or dishonesty of any Director/Partner/Principal/employee/self-employed person? YES NO If YES please provide FULL details. Date loss sustained Summary Amount of loss sustained Reserve held (if applicable) Amount paid (if applicable) 7.3. Is/Are the Practice(s) aware, after enquiry, of any circumstance that may give rise to a claim against, or loss sustained by the Practice(s) or any of the present or past Directors/Partners/Principals (other than those stated in answer to Questions 6.1 and 6.2. above)? YES NO If YES please provide FULL details. Summary Amount of circumstance, claim or loss Date of the advice leading to the circumstance or claim (if applicable) Page 16 of 20

7.4. Following any matters disclosed in 6.1. - 6.3. above, is/are the Practice(s) able to confirm that, where appropriate, remedial action has subsequently been taken to ensure that such matters will not or are now less likely to recur. YES NO If NO please provide an explanation: 8. Insurance 8.1. Has any application for insurance on behalf of the Practice(s) or any of the present Directors/Partners/Principals or, to the knowledge of the Practice(s), on behalf of their predecessors in business ever been declined or has any such insurance ever been cancelled or renewal refused? YES NO If YES please give FULL details on a separate sheet. 8.2. Pease provide the following details of your existing Professional Indemnity Insurance Policy. Expiry Date Insurer Limit Excess Premium Page 17 of 20

9. Declarations 9.1. Practice(s) Declaration I/We declare on behalf of the Practice(s) that the above statements and details are true and that I/we have not misstated or suppressed any material facts. I/We agree that this Proposal Form, together with any other information supplied by me/us, shall form the basis of any contract of insurance effected thereon. I/We undertake to inform Insurers of any material alteration to these facts occurring before completion of the contract of insurance. Signing this Proposal Form does not bind the Proposer or Insurers to complete this insurance. Signature of Partner(s)/Director(s) Name (IN CAPITALS) Practice(s) (IN CAPITALS) Date Page 18 of 20

9.2. Individual Declaration PROFESSIONAL INDEMNITY INSURANCE INDIVIDUAL DECLARATION FORM I hereby confirm, after enquiry of all appropriate staff for whom I am responsible, that I do not know of any claim or circumstance which may give rise to a claim against the Practice(s) other than those matters declared on the Proposal Form dated completed on behalf of the Practice(s). Signed: Name: Position Held: Date: Page 19 of 20

9.3. Declaration - Premium Tax Explanatory Note The regulations with respect to the payment of premium tax within the European Union have changed over recent years, in particular following the Kvaerner European High Court Judgement in June 2001. Where it was previously the responsibility of the Insured to settle their overseas premium tax liabilities locally with the relevant tax authorities, insurers are now increasingly being made strictly responsible for the collection of these tax amounts, along with the premium, and making the relevant payments on to those tax authorities. This is, of course, the same way the UK premium tax arrangements have always operated. For every country (including outside the EU, as other countries are now adopting similar regulations) where you have a domiciled office, the Practice(s) have a potential liability for insurance tax payable to the local authority. Accordingly, in order for insurers to evaluate the Practice s tax liabilities and collect the correct amount for payment to the relevant tax authorities in overseas jurisdictions (as well as in the UK), can the Practice(s) please provide a breakdown of its/their income for the last complete financial year arising from all domestic and overseas activities below. If income is derived from the United States of America or Australia, please specify the State or in Canada the Province, in which the office is domiciled. Country Income derived from each domiciled office Signature of Partner(s)/Director(s) Name (IN CAPITALS) Practice(s) (IN CAPITALS) Date Page 20 of 20