Notification of proposed change of control

Underwriting agents wishing to change a controller should, after discussing it with the Lloyd's Risk Management team, formally notify Lloyd's of the intention by completing this form.

By submitting this form, you are confirming that any tax implications in connection with corporate members impacted by this change of control have been explored with Lloyd's Taxation department.

All fields are mandatory. Where a field does not apply please enter N/A.

Notification of proposed change of control
Name of underwriting agent
Name(s) of corporate members
Name of controller being replaced
Details of new controller
Name of new controller
(If a company) Registered address and Company Registration number
Controller Type
Listing Type
Percentage
Details of complex change of control
What are the reasons for the change of controller?
What changes are anticipated to the Board, operation and / or management or the agent following FSA approval?
What, if any, are the implications for the underwriting capital and other Lloyd's interests?
Do these changes affect your corporate member(s)
Yes
No
If so, please provide further details
Contact details of person completing the form
Name
Job title
Email address
Telephone
Last updated on 19 Jan 2010