Crystal Insurance Brokers is now part of Ellis David

Have you ever been convicted of any offences involving fraud, theft, false accounting 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 protections, money laundering, market manipulations or insider dealing? (required)

Are you the subject of any current criminal proceedings? (required)

Have you any convictions for any offences other than those listed in question 1 a) above which 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)? (required)

Are you or have you ever been the subject of any civil proceedings, arbitration or litigation, including proceedings that resulted in a County Court Judgment (CCJ) or other judgement debts, in the United Kingdom or elsewhere? (required)

Are you aware of any intention to begin such proceedings against you in the future? (required)

Do you have any judgement debts (including CCJs) made under a court order still outstanding, whether in full or in part? (required)

Have you ever failed to satisfy any such judgement debts within one year of making of the order (required)

Are you or have you ever been, the subject of any bankruptcy proceedings, or proceedings for the sequestration of your estate? (required)

Have you ever entered into a deed of arrangement or an individual voluntary arrangement (or in Scotland a trust deed) or other agreement in favour of your creditors, or are you doing so? (required)

Have you ever been found guilty of conducting any unauthorised regulated activities or been investigated for possible conduct of unauthorised regulated activities? (required)

Are you, or have you ever been, the subject of an investigation into allegations of misconduct or malpractice in connection with any business activity? (required)

Have you ever, either in the United Kingdom, or elsewhere been - (required)

- refused entry to, or been dismissed or requested to resign from, any profession, vocation, office or employment, or from any fiduciary office or position of trust, whether or not remunerated? (required)

- refused, restricted in, or had suspended, the right to carry on any trade, business or profession for which specific licence, authorisation, registration, membership or other permission is required? (required)

- disqualified by a court from acting as a director of a company or from acting in a management capacity of conducting the affairs of any company, partnership or unincorporated association? (required)

- the subject of a disqualification direction under section 59 of the Financial Services Act 1986 of 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? (required)

Have you ever been a controller, director, senior manager, partner or company secretary of a company, partnership, or unincorporated association? If you answered "no" to question 8 you may proceed to section 12. Please tick (required)

In respect of activities regulated by the FCA have you, or any company, partnership or unincorporated association of which you are or have been a controller, director, senior manager, partner or company secretary, during your association with that entity and for a period of three years after you ceased to be associated with it, ever - (required)

- been refused, had revoked, restricted or terminated any licence, authorisation, registration, notification, membership or other permission granted by any such body? (required)

- been criticised, censured, disciplined, suspended, expelled, fined, or been the subject of any other disciplinary or intervention action by any such body? (required)

- resigned whilst under investigation by, or been required to resign from, any such body? (required)

- been the subject of any civil action which has resulted in a finding against you or it by a court? (required)

Has any company, partnership or unincorporated association for which you have been a controller, director, senior manager, partner or company secretary, in the United Kingdom or elsewhere, at any time during your involvement or within one year of such an involvement – (required)

- been put into liquidation, wound up, ceased trading, had a receiver or administrator appointed or entered into any voluntary arrangement with its creditors? (required)

- been declared by a court liable for any fraud, misfeasance, wrongful trading or other misconduct? (required)

- been investigated or been involved in an investigation by an inspector appointed under companies or any other legislation, or required to produce documents to the Secretary of State, or any other authority, under any such legislation? (required)

- been convicted of any criminal offence, censured, disciplined or publicly criticised, by any inquiry, by the Takeover Panel of any other governmental or statutory authority or any other regulatory body (other than as already indicated under 10 b))? (required)

Are you currently a director of any company other than one which is a part of this company? (If “yes” please give details on the supplementary sheet). (required)

Personal information provided in this form will be used by us to discharge our statutory functions under the Financial Services and Markets Act 2000 and other relevant legislation and will not be disclosed for any other purpose without the permission of the applicant.