Business Assurance Questionnaire (W1844) - Legal & General

UNDERWRITING QUESTIONNAIREBUSINESSASSURANCE QUESTIONNAIRE.Please remember that if you do not answer the following questions fully and accurately it will very likely mean that a claim will bedeclined and the policy cancelled.Where examples are shown, they are not intended to be a complete list.Full NameDate of Birth (DDMMYYYY)ReferenceWhat is the reason for the policy?If there is more than one reason forthe policy please indicate all thatapply and complete all relevantsections.Business Loan ProtectionKey Person ProtectionDirector, Partnership and LimitedLiability Share ProtectionCompany Share Buy BackOther(complete sections A, B, E and F)(complete sections A, C, E and F)(complete sections A, D, E and F)(complete sections A, D, E and F)(Complete section A and give full detailsin the ‘Additional Information’ section.)ATO BE COMPLETED FOR ALL APPLICATIONS1 Do you have, or are you applyingfor, any other Life cover withLegal & General or with anotherinsurance company?YesNoIf ‘Yes’, please give details.This includes any Life coverprovided by your employer.Policy 1 Policy 2 Policy 3If ‘Yes’ and you need more space,please use Section E, AdditionalInformation.CompanyStart datePolicy typeTermyearsyearsyearsAmount of cover£££Reason for coverWill this policy remainin force/be going ahead?YesNoYesNoYesNoDo you have any otherpolicies to tell us about?YesNoIf ‘Yes’, please give the same details as above for the other policy(ies), in Section E(Additional Information) before continuing with this section.

ATO BE COMPLETED FOR ALL APPLICATIONS – continued2 Do you have, or are you applyingfor, any other Critical Illness coverwith Legal & General or withanother insurance company?If ‘Yes’ and you need more space,please use Section E, AdditionalInformation.Yes NoIf ‘Yes’, please give details.CompanyPolicy 1 Policy 2 Policy 3Start datePolicy typeTermyearsyearsyearsAmount of cover£££Reason for coverWill this policy remainin force/be going ahead?YesNoYesNoYesNoDo you have any otherpolicies to tell us about?YesNoIf ‘Yes’, please give the same details as above for the other policy(ies), in Section E(Additional Information) before continuing with this section.3 Business detailsTrading nameNumber of employeesHow long has the business been trading?yearsmonths4 Please give turnover, gross profitand net profit (before tax) figuresfor the last three completedyears.If the business has been tradingfor between one and three years,please provide figures for allcompleted years.If the business has been tradingfor less than one year, pleaseprovide projected figures.5 Has a loss been reported in thelast two years or is a loss due tobe reported?If you answer ‘Yes’ to thisquestion please provide a copyof the last two years’ reports andaccounts.Reports and accounts are alsorequired when a certain amountof cover is reached. Please speakto your Financial Adviser to see ifthis applies to you.6 What is your exact shareholdingin the business and the currentvalue of that shareholding?Most recent yearLast yearPrevious yearProjected figuresYes NoPercentage of shares££££Turnover Gross profit Net profit (before tax)££££If ‘Yes’, please give an explanation of why this occurred and give detailsof any action taken:% Current value £££££7 Have you been investigated,arrested, charged, convictedor do you have a prosecutionpending for any of the following?Bribery, Corruption,Counterfeiting, Embezzlement,Fraud, Money laundering, Taxevasion.Investigated Arrested ChargedConvicted Prosecution pending NoIf you have been investigated, arrested or charged, please give details:Please ignore any conviction thatis spent under the Rehabilitationof Offenders Act.Please tick only one answer.Business Assurance Questionnaire page 2/5

BTO BE COMPLETED FOR BUSINESS LOAN PROTECTION8 Please give details of yourbusiness mortgage/loan orforward a copy of the fulland final loan offer from yourprincipal lender.For some applications, a copy ofyour loan offer or the latest loanstatement of interest may needto be provided. Please speak toyour Financial Adviser to see ifthis applies to you.What is the reason foryour mortgage/loan?If ‘Other’, please give details:Business premisesEquipmentExpansionName(s) of lender(s)Name(s) of borrower(s)Mortgage/loan amount £Mortgage/loan term years Interest rate %Does the term or amount of cover of this policy differ from themortgage/loan? If ‘Yes’, please explain why you require this:YesNoType of mortgage/loanRepayment basisNew or remortgageInterest onlyExisting arrangementCapital and interestIf ‘Other’, please give details:9 Are any other policies beingtaken out to cover thismortgage/loan?YesNoIf ‘Yes’, please give full details:Business Assurance Questionnaire page 3/5

CTO BE COMPLETED FOR KEY PERSON PROTECTION10 What is the total remuneration(including dividends, bonusesetc) that you have received ineach of the last three years?Current year:Last year:Previous year:£££11 What type of work are youengaged in?12 Please explain the effectyour loss would have on thebusiness.For example, profits may reduce,key contacts may be lost or youmay be the guarantor of a loan.13 Please explain how you havecalculated the amount of coverthat you need.For example, this may bethe expected loss of profitsmultiplied by the number ofyears that it would take thebusiness to recover.14 Is the business taking out anyother key person policies, onyou or any other key person,or are there any other policiesalready in force, with anotherinsurance company and/orLegal & General?YesNoIf ‘Yes’, please give full details:If ‘Yes’, please give full detailsincluding amount of cover,contract types and provider(s)names.If you need more space, pleaseuse Section E, AdditionalInformation.15 What proportion of the businessnet profit can fairly be attributedto you?%DTO BE COMPLETED FOR DIRECTOR AND PARTNERSHIP SHARE PROTECTIONDirector Share, Partnership Share, Limited Liability Partnerships (LLP) and Company Buy Back Share Protection16 What is the total value of thebusiness and how has this valuebeen calculated?Please include full details of thecalculations, for example PriceEarnings (PE) ratios, asset valuestaken into account.£17 Are any policies being takenout on other shareholders,partners or members, withLegal & General or anotherinsurance company?If ‘Yes’, please provide detailsof all applications and stateif any of these are withLegal & General.If you need more space, pleaseuse Section E AdditionalInformation.18 Does the shareholder agreement(cross option or similar) specifythe outcome in the event of acritical illness?YesYesNoNoIf ‘Yes’, please give full details:If ‘No’, please tell us why.Only answer this question ifthe policy you are taking outincludes critical illness.Business Assurance Questionnaire page 4/5

EADDITIONAL INFORMATIONPlease use this space to provide uswith any additional information.FCUSTOMER DECLARATIONI declare that the answers I have given are to the best of myknowledge and belief, true and complete.Please remember that all items of information requested in thisquestionnaire are taken into account when assessing acceptanceof the application and in calculating the premium. If you do notgive any of this information or if you mis-state any information itwill very likely mean that a claim will be declined and the policy orpolicies cancelled.I agree that this questionnaire will form part of my applicationfor life, critical illness, income protection or mortgage protectioninsurance and I also agree to inform Legal & General of any changeto this information between the date of this questionnaire and theissue of the policy contract.SIGNATURECustomerDate (DDMMYYYY):Third party signature (eg accountant, solicitor, bank manager etc)For certain applications the information given in this form needsto be confirmed by an independent third party. These are usuallyprofessional people who know the customer(s) financial affairs butare unrelated to the sale, e.g. solicitor, accountant, bank manageretc. Please see the covering letter which will advise if a third partysignature is required in this instance.I declare that the information supplied in this form is, to the best ofmy knowledge, true and complete.Signature:Please printyour nameDate (DDMMYYYY):Occupation and qualificationsAddressLegal & General Assurance Society LimitedRegistered in England and Wales No. 00166055Registered office: One Coleman Street, London EC2R 5AAWe are authorised by the Prudential Regulation Authority and regulated bythe Financial Conduct Authority and the Prudential Regulation Authority.We are members of the Association of British Insurers.W1844 12/13 NON GASDwww.legalandgeneral.com