Fitness and Propriety Questionnaire Individual Director or Controller (CM250) Name (Individual) Name of the Corporate Member Membership number (if known) CM250 (May 2012) Page 1 of 6
Introduction This questionnaire is to be completed, in block letters, by an individual ( the Applicant ) proposing to be a controller or director of a firm that is, or is applying to become, a corporate member of Lloyd s ( the Corporate Member ). For a new controller application relating to an existing corporate member, please also submit a completed and signed Change of Control Questionnaire. Application to become a Director Yes No a Controller Yes No Please indicate percentage controlling interest (if relevant) % equity interest % voting interest % interest in losses Personal Identification details Title Surname Forenames Date of birth Nationality Place of birth Passport number Please include a certified 1 copy of your passport, national identity card or copy photo driving licence with this application. Please provide details of your private address(es) in the last three years (starting with the most recent) Private address Previous address Previous address 1 Certified by FSA registered individual/company or equivalent Page 2 of 6
Personal Identification details cont d 1. Have you previously applied for Membership of Lloyd s? Yes No If yes, when and through which agent? Please give membership number if known 2. Are you an Annual Subscriber at Lloyd s? Yes No 3. Are you an Associate at Lloyd s? Yes No 4. Are you related to (or partner of) an existing/previous member of Lloyd s? Yes No If yes, please state their full name and relationship 5. Are you or have you been a director/controller of any other Corporate Member of Lloyd s Yes No If yes, please give details 6. Are you an employee or the spouse (or partner of) of an employee of the Corporation of Lloyd s or any of its subsidiaries? Yes No If yes, please give details Page 3 of 6
Employment details Give a full record of employment over the last five years. Any gaps in employment over the period must be explained. Use additional sheets if necessary. Employed/Self Employed/Retired * Delete as applicable Other-Please state.. Current employment/self employment (month and year) Name Address Nature of business Position(s) held and responsibilities Previous employment/self employment (month and year) Name Address Nature of business Position(s) held and responsibilities Reasons for leaving Previous employment/self employment (month and year) Name Address Nature of business Position(s) held and responsibilities Reasons for leaving Page 4 of 6
Fitness and Propriety The following information shall be provided in respect of events within the last ten years both in the United Kingdom and elsewhere. If the answer to any question is YES, please provide further details in a separate attachment and include copies of any relevant documents. 1 Has the Applicant ever been convicted of any offence involving fraud, theft, false Yes No accounting, offences against the administration of public justice (such as perjury, perverting the course of justice and intimidation of witnesses or jurors), serious tax offences or other dishonesty or an offence (whether or not in the United Kingdom) relating to companies, building societies, industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, consumer credit or consumer protection, money laundering, market manipulations or insider dealing? 2 Is the Applicant the subject of any current criminal proceedings? Yes No 3 Has the Applicant any convictions for any offences other than those listed above which Yes No are not spent, whether or not in the United Kingdom (excluding traffic offences unless these resulted in a ban from driving or involved driving without insurance)? 4 Is the Applicant, or has the Applicant ever been, the subject of any civil proceedings, Yes No arbitration or litigation, including proceedings that may lead to a County Court Judgment ( CCJ ) or other judgment debts, in the United Kingdom or elsewhere? 5 Is the Applicant aware of any intention to begin such proceedings against the Applicant in Yes No the future? 6 Does the Applicant have any judgement debts (including CCJs) made under a court order Yes No still outstanding, whether in full or in part? 7 Has the Applicant ever failed to satisfy any such judgment debts within one year of the Yes No making of the order? 8 Is the Applicant, or has the Applicant ever been, the subject of any bankruptcy proceedings, Yes No or proceedings for the sequestration of the Applicant s estate? 9 Has the Applicant ever entered into a deed of arrangement or an individual voluntary Yes No arrangement (or in Scotland a trust deed) or other agreement in favour of the Applicant s creditors, or is the Applicant doing so? 10 Does the Applicant have any outstanding financial obligations arising from regulated Yes No activities, which the Applicant has conducted in the past, whether in the United Kingdom or overseas? 11 Has the Applicant ever been found guilty of conducting any unauthorised regulated Yes No activities or been investigated for possible conduct of unauthorised regulated activities? 12 Is the Applicant, or has the Applicant ever been, the subject of an investigation into Yes No allegations of misconduct or malpractice in connection with any business activity? 13 Has the Applicant ever, either in the United Kingdom, or elsewhere a been refused entry to, or been dismissed or requested to resign from, any profession, Yes No vocation, office or employment, or from any fiduciary office or position of trust, whether or not remunerated b been refused, restricted in, or had suspended, the right to carry on any trade, business or Yes No profession for which specific licence, authorisation, registration, membership or other permission is required? Page 5 of 6
c been disqualified by a court from acting as a director of a company or from acting in Yes No a management capacity or conducting the affairs of any company, partnership or unincorporated association? d been the subject of a disqualification direction under section 59 of the Financial Services Yes No Act 1986 or a prohibition order, under section 56 of the Financial Services and Markets Act 2000, or received a warning notice to make such a direction or order? 14 In respect of activities regulated by the FSA or any other regulatory body, has the Applicant, or has any company, partnership or unincorporated association of which the Applicant is or has been a controller, director, senior manager, partner or company secretary, during the Applicant s association with that entity and for a period of three years after the Applicant ceased to be associated with it, ever a been refused, had revoked, restricted or terminated, any licence, authorisation, Yes No registration, notification, membership or other permission granted by any such body? b been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of Yes No any other disciplinary or intervention action by any such body? c resigned whilst under investigation by, or been required to resign from, any such body? Yes No d decided, after making an application for any licence, authorisation, registration, notification, Yes No membership or other permission granted by any such body, not to proceed with it? e been the subject of any civil action which has resulted in a finding against the Applicant or Yes No it by a court? 15 Has any company, partnership, or unincorporated association of which the Applicant is or has been a controller, director, senior manager, partner, or company secretary, in the United Kingdom or elsewhere, at any time during the Applicant s involvement or within one year of such an involvement a been put into liquidation, wound up, ceased trading, had a receiver or administrator Yes No appointed or entered into any voluntary arrangement with its creditors? b been adjudged by a court liable for any fraud, misfeasance, wrongful trading or other Yes No misconduct? c been investigated or been involved in an investigation by an inspector appointed under Yes No companies or any other legislation, or required to produce documents to the Secretary of State, or any other authority, under any such legislation? d been convicted of any criminal offence, censured, disciplined or publicly criticised, by any Yes No inquiry, by the Takeover Panel or any governmental or statutory authority or any other regulatory body (other than as already indicated under 14(b) above)? I hereby certify that the information supplied to Lloyd s is, to the best of my knowledge and belief, accurate in all material respects and does not omit any information relating to me which might reasonably be considered relevant to my application to become a controller or director of a corporate member of Lloyd s. Furthermore, I hereby undertake and agree that I shall immediately notify Lloyd s of any changes in the information provided in this form which occur after the date of submission of this application. Signature Date Page 6 of 6