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Please state total fees derived from financial advice that was/is directly regulated by the FCA (formerly the FSA):

Last financial year when FCA work was carried out ending: Current financial year ending:

Date Date

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

Last financial year whenFCA work was carried out

Current financial year

Investment in Unit Trusts or Investment Trusts

UK % %

Offshore including Channel Isles and Isle of Man % %

Investment in Insurance Bonds

UK % %

Offshore including Channel Isles and Isle of Man % %Investment in Listed/Unlisted Securities

UK % %

Offshore including Channel Isles and Isle of Man % %

Investment in Commodities % %

Investment in Bonds % %

Investment in Tangibles (eg. fine art) % %

Institutional Fund Management % %

Split Capital Investment Trusts % %

Endowments including Mortgage Endowments % %

Pensions and Free-standing AVCs % %

Life Assurance Products including whole of life plans % %

Corporate Finance % %

Home Income Plans/Equity Release Schemes % %

Other (please give full details) % %

Total: 100% 100%

Do you manage or have you managed any discretionary portfolios on behalfof any client? (if yes, please provide a detailed explanation below) Yes No

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

Has your firm ever been the subject of a complaint made to the Financial OmbudsmanService or any equivalent professional organisation? (if yes, please provide a detailedexplanation below)

Yes No

Does your firm undertake any activities which are defined in the Insurance MediationDirective 2002/92/EC and are subject to the Directives Professional Indemnity InsurancePII) requirements?

Yes No

Name of Practice

Indemnity Risk SolutionsFinancial Services Questionnaire 2013

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Pension Transfers and Opt-Outs, Free-standing AVCs, Mortgage Endowments and Split Capital Investment Trusts

(a) Has your firm at any time given advice on, or been involved in arranging Pension Transfers/Opt-Outs/Non-Joiners? Yes No

.

IfYes, in what capacity did your firm act:

As a Financial advisor providing advice to clients? Yes No

As an introductory agent only for a permitted Third Party Yes No

Please also provide details of:

Gross fees (including commission) received from these activities

Number of pension cases dealt with by your firm

How many cases have been reviewed by your firm?

How many cases are yet to be reviewed?

How many Review cases require redress?

What is the average redress for these cases?

(b) Has your firm at any time given advice on, or been involved in arranging Free-Standing Additional

Voluntary Contributions (FSAVCs)? Yes No

IfYes, please complete the following:

How many FSAVCs were effected in total?

What is the average contribution in respect of these FSAVCs?

How many cases require Review within the stipulations of the FCA?

How many Review cases require redress?

What is the average redress for these cases?

(c) Has your firm at any time given advice on, or been involved in arranging Mortgage Endowments? Yes No

IfYes, please provide the details of:

Gross fees (including commission) received from these activities

Number of policies arranged

Any compensation paid in respect of these activities

(d) Has your firm at any time given advice on, or been involved in arranging Split Capital Investmenttrusts? Yes No

IfYes, in what capacity did your firm act?

As a financial advisor providing advice to clients Yes No

As an introductory agent only for a permitted Third Party Yes No

Please also provide details of:

Gross fees (including commission) received from these activities

Percentage relating to investment in Zero Dividend Shares? %

Percentage relating to investment in Income Shares? %

Percentage relating to investment in Capital Shares? %

(e) Has your firm at any time given advice on, or been involved in arranging Payment ProtectionInsurance (PPI)? Yes No

Number of policies pre 14 January 2005

Number of policies post 14 January 2005

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Declaration

CONFIRMATION

I/We warrant and declare that I/We have made full enquiry of all professional staff and that the particulars and statements in thisproposal are true and complete and any other documentation and information provided in connection with this proposal is trueand complete. I/We agree and accept that this proposal and declaration and the documentation and information which isprovided (or should be provided) will be the basis of contract with Insurers. I/We also warrant and declare that I/We haveinformed the Insurer of all facts which are likely to influence the Insurer in the assessment or acceptance of this insurance.

I/We understand that failure to inform Insurers of all material facts, including but not limited to any circumstance which might giverise to a claim, could invalidate this insurance. I/We accept that if I/We am/are in doubt whether any fact may influence theInsurer I/We should disclose it. I/We also understand that I/We have a continuing obligation to disclose all material facts untilcommencement of the policy.

I/we accept that all data collected by IRS will be held in accordance with the Data Protection Act 1998 and that IRS may disclosethis information only in order to obtain quotations for my/our practices professional indemnity insurance.

Signing this form does not bind you to accept any quotation provided by Indemnity Risk Solutions.

THIS PROPOSAL FORM MUST BE SIGNED BY APRINCIPAL/MEMBER/DIRECTOR OF THE FIRM

Signature(Principal/Member/Director)

Date 2013

Print Name(Principal/Member/Director)

PLEASE RETURN THIS FORM TO:

Indemnity Risk SolutionsBirchin Court3rd Floor20 Birchin LaneLondon. EC3V 9DUTel: 020 7264 1260Fax: 020 7702 2894Email: enquiries@indemnityrisksolutions.co.ukWebsite:www.indemnityrisksolutions.co.uk

Indemnity Risk Solutions and Ink Insurance are trading names of Ink Underwriting Agencies Ltd.Registered in England: Registration No. 3110970 Registered Office: Birchin Court, 3rd Floor, 20 Birchin Lane, London EC3V 9DU.Ink Underwriting Agencies Ltd is authorised and regulated by the Financial Services Authority.The Financial Services Authority does not regulate all forms of the products and services we provide.

mailto:enquiries@indemnityrisksolutions.co.ukhttp://www.indemnityrisksolutions.co.uk/http://www.indemnityrisksolutions.co.uk/mailto:enquiries@indemnityrisksolutions.co.uk