Excess SIPC Application. London Customer Insurance Application (US)

Transcription

1 Excess SIPC Application London Customer Insurance Application (US) (Please Type or Print in Ink) Check one Init ial Renewal Dat e. A. Legal Name and address.,.. Dat e est ablished.. B. Customer Net Equities (CNE) : Tot al $. As of. (Dat e) 1 (Add equit ies in each cust omer cash or margin account. Neglect unpriced securit ies, but foot not e if believed t o be over 5% of priced t ot al. Include account s carried on disclosed basis for correspondent s. 2 At t ach dist ribut ion t able of number of account s over $500,000 in increment s of $100,000, i.e. $500,000 - $600,000, $600,000 - $700,000, et c. Do not bunch high level account s. 3 Number of Act ive Cust omer Account s (per last quart erly st at ement ).. 4 Number of Cust omer Account s wit h equit y above $500,000:.. 5 Number of Disclosed Account Correspondent s.. C. Financials, 2+ years: FY ended. FY ended Current FYTD. From FOCUS Tot al Capit al (line 3530) Net Capit al (line3750) Excess Net Capit al (line 3770 or 3910) Capit al Rat io (line 3780 or 3851) FY P&L aft er t ax Submit 1 Lat est FOCUS Report 2 For init ial applicat ions, submit t wo most recent Audit ed Financial Report s, wit h Account ant 's Comment Let t er t o Management, if any. For renewal applicat ion, most recent only. D. Firm Operations: 1 % of cust omer business: equit ies %, bonds %, government s %, mut ual funds %. Cust omer base: Inst it ut ional %, Ret ail %. Int ernet. % Discount. % No. Discret ionary and Managed Account s. 2 Market maker?. size $. 3 Repo mat ched book? size $. 4 St ock Loan mat ched book? size $. 5 No. employees producers, operat ions. No. Branches. 6 At t ach descript ion of any day t radiing, market making or int ernet on line t rading facilit y by your firm or disclosed account int roducing correspondent s wit h descript ion of relat ed risk cont rols. 1

2 E. Broker's Blanket Bond: Underwrit er. Size $ Deduct ible $.. (At t ach descript ion of any claims paid or made during t he past t wo years.) 2

3 F. Submit the following other information: 1 Examiner's report s of past t wo years for original applicat ions, past year for renewals. Include firm's reply if any. Not e any examinat ion for which report is not yet received. Supply exit int erview not es. 2 Descript ion of any significant change in t he firm's business during t he past year. Explain any capit al or cont rols relat ed t o such business added. 3 If firm is a unit in a corporat e family, Organizat ion Chart of Cont rolling Persons, showing capit al int erest and cont rol percent age of parent s. Include annual report or similar informat ion on ent it y cont rolling t he group wit h financial st at ement. For firms not unit s in a corporat e family, indicat e cont rolling persons. 4 Descript ion, explanat ion, and relat ed regulat ory correspondence of regulat ory violat ions or deficiencies (ot her t han t hose in submit t ed examiners report s), disciplinary act ions t aken or pending against t he firm or it s principals, special clearing corporat ion requirement s, et c. Check here if t here were none. 5 For original applicat ions, submit names and securit ies indust ry backgrounds of Principal Officers, especially CEO and CFO. For renewals, submit such informat ion on changes during past year. G. Customer insurance quotation requested: 1 Combined ret urn per eligible cust omer from Trust ee, SIPC and London of $. million. Aggregat e limit by London $. million. Cover Securit ies Only.. or Cash and Securit ies.. 2 For cover of individual account s, SIPC ineligible account s, net free credit balances, sub mit descript ion of account (s), size, insurance desired. 3 For cover purchased by an int roducer t o assist it s cust omers carried by anot her firm, complet e Supplement on Page 3. H. Agreement [ check designat ed regulat or(s)] The designat ed regulat or(s) of t he applicant is/ are t he New York St ock Exchange and/ or Nat ional Associat ion of Securit ies Dealers. The applicant hereby applies for quot at ion of cust omer insurance supplement ing SIPC coverage by Syndicat es at Lloyd's of London and ot her Br it ish companies. This paragraph aut horizes t he st aff of t he NASD, NYSE or SIPC t o discuss wit h t he agent of t he Underwrit ers, Robert M. Bishop, or ot her agent as may be appoint ed from t ime t o t ime, t heir percept ion of our financial responsibiilit y, operat ing st at us, rule compliance, and management, and t o read relevant document s from t heir files, all supplement ing report s and informat ion we have furnished t o t he Underwrit ers, and t o verify t he informat ion we have furnished as part of our applicat ion for Cust omer Insurance. The informat ion disclosed in t his applicat ion will be held in confidence by t he Underwrit ers and t heir agent s..... Legal Name of Applicant Signature of Officer or Partner ( ). ( )... Telephone Fax Printed name & title of Signer 3

4 SIGNING OF THIS FORM DOES NOT BIND THE APPLICANT OR THE UNDERWRITERS TO COMPLETE THIS INSURANCE 4

5 Supplement to London Customer Insurance Application (US) For firms which introduce on a disclosed basis to another firm some or all customer accounts A. Legal Name., Dat e. B. Do not complet e Sect ion B on Page 1 of Applicat ion. Inst ead complet e following: Self-carried Customer Net Equities (CNE) : Tot al $. As of. (Dat e) Introduced Customer Net Equities: Tot al $. As of. (Dat e) 1 (Separat ely for self-carried and int roduced account s, add equit ies in all cust omer cash or margin account s. Neglect unpriced securit ies, but foot not e if believed t o be over 5% of priced t ot al). 2 Separat ely for self-carried and int roduced account s, at t ach dist ribut ion t able of number of account s over $500,000 in increment s of $100,000, i.e. $500,000 - $600,000, $600,000 - $700,000 et c. Do not bunch high level account s. 3 Act ive Cust omer Account s (per last quart erly st at ement ) Self.. Int roduced.. 4 Cust omer Account s wit h equit y above $500,000: Self.. Int roduced.. 5 Submit names of firms t o which cust omer account s are int roduced on a disclosed basis. For each, submit t heir t ot al cust omer net equit y and a recent public financial st at ement or capit al comput at ion pages of t heir FOCUS report. G. Do not complet e Sect ion G on Page 2 of Applicat ion. Inst ead complet e following: Customer insurance quotation requested: For self carried accounts only, for introduced accounts only, for both Cover for Securities only or for both Securities and Cash. 1 Combined ret urn per eligible cust omer from Trust ee, SIPC and London of $. million. Aggregat e limit by London $. million 2 For cover of individual account s, SIPC ineligible account s, net free credit balances, submit descript ion of account (s), size, insurance desired. 5