Safe&Secure Insurance Services, providing home building and contents insurance cover within the united kingdom

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(Required by the FCA) 
 
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In any one month, on average, I write the following mortgage
applications (please tick)
 

  0 - 5
 
  6 - 10
  11 - 15
 
  16 - 20
  20+
   
     
     
     
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              Terms & Conditions

Please Note: By selecting accept you also agree to receive news letters and mail shots from Safe&Secure.

 

Introducer Appointed Representative Questionnaire

Statement of Honesty, Integrity and Reputation

Please answer the following questions by ticking the appropriate box.  Where a “Yes” box is ticked, please provide full details.

   

Yes

No

Are you, or have you ever been, the subject of, or are you aware of any intention to begin against you, either in the UK or elsewhere:

Q1a. any civil proceedings, or litigation, including judgement debts or arbitration?    
if answer yes please give details:
              
Q1b. any bankruptcy proceedings, or proceedings for the sequestration of your estate, including entering into a deed of arrangement, an individual voluntary arrangement (or in Scotland a trust deed) in favour of your creditors, or other composition, or arrangement with creditors?    

if answer yes please give details:

 

If you have been the subject of any judgement debts under a court order, have you:

Q2a. any such debts still outstanding, whether in full or in part?    

if answer yes please give details:

 
Q2b. failed to satisfy any such debts within one year of the making of the order?    

if answer yes please give details:

 

Have you ever, either in the UK or elsewhere:

Q3a. been refused entry to any profession or vocation, or been dismissed or requested to resign from any office or employment, or from any fiduciary office or position of trust, whether or not remunerated?    

if answer yes please give details:

 
Q3b. been refused, or restricted in, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required?    

if answer yes please give details:

 
Q3c. been disqualified by a court from acting as a director of a company or from acting in a management capacity or from conducting the affairs of any company, partnership or unincorporated association?    

if answer yes please give details:

 

Have you, or has any company, partnership, or unincorporated association of which you are or have been a controller, director, partner, manager or company secretary, whilst you were associated with that entity and for a period of three years after you ceased to be associated with it, in respect of activities falling within the jurisdiction of a Regulatory Authority or any other professional body, ever:

Q4a. been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body?    
 

if answer yes please give details:

 
Q4b. been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any such body?    

if answer yes please give details:

 
Q4c. resigned, or been asked to resign, from any such body or, after making a notification or application for any licence, authorisation, registration, membership or other permission granted by any such body, decided not to proceed with it?    

if answer yes please give details:

 
Q4d. been the subject of any civil action that has resulted in a finding against you or it by a court?    

if answer yes please give details:

 
Q4e. knowingly been the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity?    

if answer yes please give details:

 

Has any company, partnership, or unincorporated association of which you are or have been a controller, director, partner, manager or company secretary, in the UK or elsewhere, at any time during your involvement:

Q5a. been put into liquidation, had a petition presented, or a meeting summoned to consider a resolution, to wind up the company, or been wound up, had a petition for bankruptcy presented, or been declared bankrupt?    

if answer yes please give details:

 
Q5b. ceased trading in circumstances in which one or more creditors did not receive full payment, had a receiver or administrator appointed, or entered into (or made any proposal to enter into) any arrangement with creditors, or made a trust deed for creditors, or been dissolved?    

if answer yes please give details:

 

Have you ever, or has any company, partnership, or unincorporated association of which you are or have been a controller, director, partner, manager or company secretary, in the UK or elsewhere, at any time during your involvement:

Q6a. been adjudged by a court liable for any fraud, misfeasance, wrongful trading or other misconduct towards a Regulatory Authority or towards any members or creditors of a Regulatory Authority?    

if answer yes please give details:

 
Q6b. been investigated by an inspector appointed under companies or any other legislation, or required to produce books and papers to the Secretary of State?    

if answer yes please give details:

 

 

Established 2001        FCA Registered No. 300564 

Calls may be recorded for training purposes

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Registration

 
 

 

  The UK's No.1 General Insurance Broker

Tel: 01332 200888