20100903 AnnualComplianceQuestionnaire by nuhman10


									     Annual compliance questionnaire for

1.     Throughout this document the term “you” or “your” means the Lloyd‟s Approved Coverholder.

2.     Please complete this questionnaire annually when requested and return to your Lloyd‟s broker
       who will forward the information to those Underwriting Members of Lloyd‟s who underwrite your
       binding authority (ies) at Lloyd‟s (“the Underwriters”).

3.     Lloyd‟s has designed this standard compliance questionnaire for completion by you so that you
       may provide, in a single document, information required by the Underwriters to consider the
       renewal of your binding authority(ies) and to demonstrate that you continue to meet the criteria to
       be a Lloyd‟s approved coverholder. Its purpose is to eliminate the need for different questionnaires
       from the Underwriters asking for the same core information.

4.     You are reminded that you have an obligation to notify the Underwriters, your Lloyd‟s broker and
       Lloyd‟s immediately of any material changes to information contained within this questionnaire,
       being matters of which the Underwriters, your Lloyd‟s broker and Lloyd‟s would reasonably expect
       notice. In practice this should be achieved by advising your Lloyd‟s broker who will communicate
       the information to the relevant parties.

5.     If you have two or more binding authorities at Lloyd‟s which have different renewal dates, your
       Lloyd‟s broker may ask you to update this questionnaire for each renewal but this can be achieved
       by an E-mail confirmation that there are no changes to the information previously provided or by
       re-signing and dating the declaration at the end of this form.

 Checklist of additional information
 The completed questionnaire should have the following documents attached                            Attached
 A copy of your latest accounts and annual report
 A copy of your current Professional Indemnity or Errors and Omissions policy
 A copy of any applicable current Fidelity insurance
 A copy of your new or renewed licenses
 Resume / CV of any new individual listed in the „Key staff‟ section
 If your company ownership changes, please provide a chart showing any relationship and
 ownership of all companies in the group.

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     Annual Compliance Questionnaire

 Company information
 Coverholder PIN

 Legal name

 Trading name(s)

 Registered Address

 Trading Address

 Postal address






 Please provide details for any changes listed above

 Ownership of the Company
 Please provide details of any change in ownership in the last twelve months and complete the table. If
 ownership has changed please complete the following tables.

 Company Name                    Registered Name              Country of            Start date   Shareholding
                                                              incorporation                               %

 Individuals owning over a 10% share of equity in the applicant company:
 Title       First Name          Last Name             DoB            Nationality   Start date   Shareholding

 Total percentage:

Insert additional lines as required
Date of Birth (D.o.B) must be filled in as DD/MM/YY

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     Annual Compliance Questionnaire

Key staff
Have there been any changes to persons authorised or responsible under the Binding Authority
Agreement(s), in the last twelve months, including:
1. The person(s) responsible for overall operation and control of binding authorities (Y/N)
2. The person(s) authorised to bind insurances (Y/N)
3. The person(s) with overall responsibility for the issuance of documents evidencing insurances
   bound (Y/N)
4. The person(s) authorised to exercise any claims authority granted by the agreement (Y/N)

 Please complete the following information for new Key staff
 Title      First Name                 Last Name                  DoB         Nationality                Start date

 Is this individual directly employed by the coverholder?*                    Time spent on binder %
 Responsible for (please circle)
                                   1                                    Principal           Alternate   Other
                                   2                                    Principal           Alternate   Other
                                   3                                    Principal           Alternate   Other
                                   4                                    Principal           Alternate   Other

*If an individual is not directly employed by the applicant please provide details in the comments section
It is a requirement of the Binding Authority that all such changes must be prior agreed by Underwriters.
Date of Birth (D.o.B) must be filled in as DD/MM/YY

 Professional indemnity
 This section must be completed
 Does your professional indemnity (PI) cover Lloyd‟s binding authorities? (Y/N)
 Name of PI Insurer
 Rating Company*                                             PI Insurer rating*
 Start date                                                  Expiry date
 Limit: individual loss                                      Limit: agg. of losses
 Deductible individual loss                                  Deductible: agg. of losses
 Do your policies extend to acts of dishonesty of employees? (Y/N)
 If not, do you purchase a separate Fidelity insurance policy? (Y/N)
 Do you have any additional lines of PI cover? (Y/N)
 Named companies covered
 No. of PI claims made in the last 12 months (please supply details for each claim below)
 Year                                     Currency                                Amount

* This information is not mandatory

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   Annual Compliance Questionnaire

Details of the licences, permits or other authorisations which you need under the jurisdiction in which you are
domiciled, trading, providing services or doing business, or in any other jurisdiction where you need to hold
such a licence in order to enter into contracts of insurance on behalf of Lloyd's underwriters, act as an
insurance intermediary, and act as a Lloyd's coverholder:
Licence name
Regulatory body
Licence area                                                Expiry date
Company or individual                                       Individual's name

Are accounts management or audited?                                     Currency
Accounting period from:                            Accounting period to:
Company legal status       Chapter s         Inc              LLP                  Ltd           Other

Bank accounts
Please complete this information if there have been changes in the last 12 months
Do you have separate bank accounts for insurance and non-insurance monies? (Y/N)
Do you have separate accounts for claims monies? (Y/N/Not Applicable)
Please explain how insurance and non-insurance monies are managed:

Account type:                                         Name of bank:
Account name:                                         Account number:
Branch sort code:                                     Trust or sweep:
Address of bank:
Signatories:         (a minimum of two must be provided)

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    Annual Compliance Questionnaire

 Reputation & standing
 The good reputation, character and financial standing of Lloyd‟s coverholders and their principal personnel is
 extremely important. For this reason, you must provide information that may be relevant to your annual
 compliance review or to Lloyd‟s decision on your application.
 In particular please confirm whether your company or any of your principal personnel have:
 Been charged with or convicted of a criminal offence other than a minor motoring offence in       Yes       No
 the last twelve months
 Been a party to any legal action, or if any legal proceedings have been commenced to which        Yes       No
 your company is a party or are any such actions pending in which your company has been
 named as a defendant in the last twelve months
  Been subject to any application for liquidations, receiverships, bankruptcy or similar           Yes       No
  proceedings or been subject to an administrative order
 Entered in to or propose to enter in to an agreement or assignment with creditors or              Yes       No
 otherwise acknowledge insolvency
 Been disqualified under company law                                                               Yes       No
 Been criticised, fined disciplined, suspended or expelled by any insurance industry, trade        Yes       No
 association or regulatory body
 Had a licence or authorisation to conduct insurance business refused, suspended, withdrawn        Yes       No
 or not renewed
 Been asked to resign (other than taking redundancy) or been dismissed from any previous           Yes       No
 office or employment
        In the space below, please provide any relevant details or enter “None”. (All principal
                  personnel should read and approve the information given below.)

Annual compliance declaration

I/We hereby declare that the information given in this compliance questionnaire for binding authorities is
true and complete and agree to it being provided to the Underwriters.

I/We also undertake to immediately advise my/our Lloyd's broker of any material changes to the
information provided. This undertaking is to be a continuous obligation.

I/We hereby declare to abide by all terms and conditions stated in the Binding Authority Agreement(s)
issued by Lloyd's Underwriters during the period of cover.

I/We hereby declare that the company and staff hold all the licences required to enter into contracts of
insurance on behalf of Underwriters, act as an insurance intermediary and act as a Lloyd's coverholder.

 Authorised signatory


 Position in your company

 Date (day/month/year)

*Electronic signatures will not be accepted

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