This Summary of Cover is designed as a guide only to the cover provided. Full details can be obtained from Keegan and Pennykid (Insurance Brokers) Ltd.

I/We declare that

• The Proposer (including any principal, partner, director, volunteer or manager of the Proposer) has not been involved in any legal proceedings or other form of legal action in the last five years
  
• The Proposer has never been refused legal expenses insurance or had it terminated by an insurer or been required to accept special conditions and/or an increased premium
  
• The Proposer is not aware, after enquiry, of any circumstances which may give rise to a claim being made under this insurance or otherwise affect the insurer's assessment of this risk
  
• The above statements made by me/us or on my/our behalf are to the best of my/our knowledge and belief true and complete and
  
  I/We agree that this proposal will form the basis of the contract between me/us and the insurer, and agree to accept a policy in the insurer's usual form for this insurance.

Name of Director/Trustee/Office Bearer who is submitting this form:

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