Administration Bond Proposal Form

Administration Bond Proposal

Please provide the following information using CAPITAL LETTERS and ticking boxes where appropriate. Please give additional information, where required, by covering letter.

AMOUNT OF BOND REQUIRED

(double amount of Gross Estate including current market value of immovable property)

1 Proposed ADMINISTRATOR/ADMINISTRATRIX

2 Deceased

3 Beneficiaries

State fully how it is proposed to deal with the shares of any minor beneficiaries or beneficiaries who are not sui juris

(b) Have all beneficiaries been traced?

YES NO

If NO, state in detail the enquiries that have been made and if application will be made to the Court

(c) Are any life interests involved?

YES NO

If YES, state the steps that will be taken to safeguard the assets

4 The Estate

(a) Is leasehold and/or real property being sold?

YES NO

If NO, how will each beneficiary get his/her share?

(b) Did the deceased carry on a business?

YES NO

If YES, state how it is proposed to deal with this

(c) Is any litigation threatened, pending or proceeding in connection with the Estate?

YES NO

If YES, give full details

(d) Will statutory advertisements for claims against the Estate be published?

YES NO

If NO, state reason and that you are satisfied all debts have been traced

(e) Has any administration taken place already?

YES NO

If YES, give details

(f) How long do you estimate it will take to complete the administration?

Has a proposal been submitted to any other surety or has private security been sought

YES NO

If YES, give details

Please attach a copy of your current Professional Indemnity Insurance Certificate, Please tick if already provided.

IMPORTANT: WHERE BOND EXCEEDS €200,000 PLEASE SUPPLY A COPY OF THE AFFIDAVIT FOR REVENUE

Important

You must tell us any other facts which are likely to affect whether we agree to provide cover, or how we assess the risks proposed for insurance. If you are not sure whether you should tell us about something, please tell us anyway. This is for your own protection because, if you do not give us all the information we need, your policy may not provide you with the cover you need, or the policy could be declared invalid and void.

Under the third EU Non-life Directive we must give you the following information before you buy your policy.

The law that applies to the contract - Under the relevant European and Irish laws, we Aviva Insurance (Europe) plc and you, the proposer, are free to choose the law that will apply to the contract. We propose that Irish law will apply to the contract, We, Aviva Insurance (Europe) plc, will provide the insurance under this policy.

Complaints procedure - We aim to give excellent service to all our customers; however, we recognise that things may occasionally go wrong. We will do our best to deal with your complaint as effectively and quickly as possible. If you arranged your cover through an agent or adviser, please send your complaint to them. If your complaint is not sorted out to your satisfaction, please contact:

Customer Feedback Team, Aviva Insurance (Europe) plc, One Park Place, Hatch Street, Dublin 2
CallSave: 1850 36 37 38
E-mail: complaints@aviva.ie
Website: www.aviva.ie

You can also write to the Managing Director, Aviva Insurance (Europe) plc, One Park Place, Hatch Street, Dublin 2 or you can contact the following

• The Irish Insurance Federation’s Insurance Information Service, 39 Molesworth Street, Dublin 2
Phone: 01 676 1914
Fax: 01 676 1943
E-mail: iis@iif.ie
Website: www.iif.ie

• The Financial Services Ombudsman Bureau, 3rd Floor, Lincoln House, Lincoln Place, Dublin 2
Phone: 01 662 0899
LoCall: 1890 88 20 90
Fax: 01 662 0890
E-mail: enquiries@financialombudsman.ie
Website: www.financialombudsman.ie

You will not lose your right to take legal action if you contact either of the above.

DATA PROTECTION - Aviva Insurance (Europe) plc (“we”, “us” or “our”), as data controller, will keep the information you provide about yourself and about third parties confidential. We may use it to advise on, provide and administer insurance products and financial services provided by us or other Aviva companies and sometimes with our affiliates and/or commercial partners, in order to comply with legal obligations imposed on us. We may share the information both inside and outside of the European Economic Area, in confidence, for these purposes with agents or service providers we have appointed, private investigators, regulatory organisations, other insurance and financial services companies (directly or via a central register), other Aviva group companies, those to whom we outsource certain business operations and as required by law. We will process this information and store it on our computer and manual record systems.

To assist in preventing, detecting and/or protecting our customers and ourselves from theft and fraud, we may use your information to make searches of our or other Aviva companies’ records. If you give us false information or fail to disclose information and we suspect fraud, we will record this. We also participate in industry databases such as those operated by the Irish Insurance Federation for the purpose of sharing of information among insurance companies as a check against non-disclosure.

From time to time, we may record your telephone calls for verification and training purposes.

If you would like a copy of the details we hold about you, please write to the Regulation and Compliance Manager, Aviva Insurance (Europe) plc, One Park Place, Hatch Street, Dublin 2. Please enclose the correct fee (€6.35). You also have the right to correct any errors in the information held about you, block certain uses or object to the processing of your personal data.

Declaration

We confirm that, having made due and diligent enquiries, that all the answers above are correct and complete and that we have not withheld, mis-stated or misrepresented any information material to the issuing of a bond.

FOR COMPLETION BY THE PROPOSED ADMINISTRATOR/RIX

I/We

confirm my/our authorisation to (Solicitors)

to propose on my/our behalf to the Aviva Insurance (Europe) plc (the Company) for an Administration Bond in the matter of the Estate of

and further, undertake and agree that the conduct and control of the administration of the said Estate shall not be taken out of the hands of the said solicitors without the written consent of the Company.

Witness

Address

Occupation