Sourcing form – LSK Risk Management

Have you had insurance or a proposal cancelled, withdrawn, declined or made subject to special terms? *

Have you been declared bankrupt or become insolvent or made any voluntary arrangement with creditors or been subject to enforcement of a judgement debt either in a personal capacity or as a business? *

Have you been convicted of or charged with any offence (including a civil penalty from the UK Border Agency), other than a motoring offence or conviction spent under the Rehabilitation of Offenders Act 1974? *

If you have answered yes to any of the above, please advise in the box below:

Name of company (ltd company, individual or partnership) *

Correspondence address *

Number of years’ experience in property *

Projected turnover *

Any employees? If so, what is your projected wage roll. *

Name *

First

Last

Email *

Contact number *

Please note, by requesting a quotation, you are accepting the following statements 1-9: 1. No legal advice is given or work is undertaken that is regulated by the Financial Conduct Authority. 2. No investment, mortgage or loan advice/provision work is undertaken. 3. No advice is given regarding contaminated land, asbestos or pollution. 4. No structural design work is undertaken. 5. No accountancy or tax work is undertaken. 6. No insolvency or valuation work is undertaken. 7. No more than 25% of the fee income emanates from the USA and/or Canada. 8. Any rent reviews undertaken have robust diary systems and risk management procedures to monitor rent review renewal dates. 9. The policyholder is not aware of any claims or suits or circumstances, allegations or contentions as to any incident which has or may result in a claim within the last 5 year. *

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