Legal Expenses Insurance Proposal Form

This form helps the insurer to decide whether to insure you and if so, on what terms. You must therefore tell us anything about your crypto investments that could influence our decision.

This includes details about, for example, the nature of your crypto assets, the blockchains or exchanges you have used, other investments you may hold, your insurance history, and your tax status.

Important notice to you about completing this proposal form

Insurance is a contract between the insurer and you the insured. Because you know more about the material facts, and therefore the risk we might take by providing insurance, the law imposes a positive duty on you to disclose anything which might: (a) adversely affect our decision to provide cover; and (b) impact the terms we are willing to offer.

The Insurance Act 2015 imposes on you a duty of ‘fair presentation’, which requires you to ensure that every material representation you provide relating to the facts and your expectations or beliefs is made in good faith.

Put another way, you must tell us everything which you know or ought to know which might impact our decision to insure you.

Failure to provide us with all relevant material at the outset may void any contract of insurance or entitle us to terminate such contract immediately and without liability.

What you should do

  • All questions must be answered. If not applicable, state n/a.
  • If there is insufficient space to provide answers, further information should be added to the additional details box.
  • Where possible, details or a screenshot of the platform you are using for your crypto investment should be provided.

If in doubt as to the meaning of any question raised in this proposal form, or your obligations relating to fair presentation and good faith representations, please contact Cypher Tracer Limited.

Failure to provide us with comprehensive information in an appropriate manner may adversely affect our appetite for the risk or ability to offer you terms.

    Declaration

    The purpose of this declaration is to clarify the nature of the crypto asset and the platform used. Matters such as the type of investment product and the exchange or blockchain are material to the risk we take and protecting you against fraud. All answers must be given to the best of your knowledge and belief. All material facts must be disclosed to us now. Both these obligations arise from your duties under the Insurance Act 2015.Your answers may affect our assessment of the risk, or the decision of our underwriters. If you are in any doubt as to how to answer a question fairly and honestly, you should consult your insurance broker or contact us directly.


    1) Has any insurer ever refused you commercial legal expenses insurance, imposed special terms, or declined to renew such a policy?


    2) Have you been involved in any dispute or legal proceedings about crypto assets to which this type of insurance would apply during the last five years?


    3) Are you aware of any cause, event, or circumstance that might give rise to a valid claim under this policy if the policy were currently in effect?


    4) Do you have more than two other existing crypto assets for which this type of insurance would apply?


    5) Do you live and work in the UK for tax purposes?


    6) Do you hold any other nationality other than British, and if so which?


    7) Is this your first crypto investment?


    8) Do you have any unspent criminal convictions for fraud or dishonesty resulting in a period of imprisonment (whether immediate or suspended)?


    Additional details

    If you have answered ‘yes’ to any of the questions on the previous page, please add supporting details here.


    Information about you


    First Name of Applicant:


    Surname of Applicant:


    Address Line 1:


    Address Line 2:


    County/City:


    Postcode:


    Country:


    Phone Number:


    Email:


    Cover


    Add the GBP equivalent of amount to be invested:

    This is the $ GBP equivalent of any crypto asset at the time of purchase, or the amount of $GBP you are paying for a crypto asset. It must be over $250,000.

    Limit of Indemnity cover is fixed at $250,000


    Crypto asset type (if known):

    BTC, NFT, DAO etc


    Intended investment:

    What asset are you going to purchase?


    Public facing Wallet ID or address:

    These address values will vary depending on the protocol used. Once it moves from that ID outside the intended investment, it will no longer be insured.


    Inception date of cover:


    How long will the crypto asset be invested for (years)?:

    Cover is provided for 12 months.

    Declaration

    By agreeing to this proposal form, you consent to Cypher Tracer Limited using the information we hold about you for the purpose of providing insurance advice and, where appropriate, assistance in relation to handling claims (if any), which may include processing your sensitive personal data (for example, data about criminal convictions) where necessary. This may mean we have to transfer your personal data to third parties involved in the process of assessing your circumstances and (if applicable) providing you with insurance cover.These third parties may include insurance carriers, third-party claims adjusters, fraud prevention and detection service providers, reinsurance companies and regulatory authorities. In the course of performing our obligations to you, this information may also be disclosed to agents and service providers appointed by us, insurers, reinsurers and their legal advisors, loss adjusters, and agents (any of which may be in the UK, outside the UK, or outside the European Economic Area).Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both for the disclosure of such information to us, and its subsequent use by us as set out in this document and our privacy policy.

    The information provided will be treated in confidence and in accordance with the data protection principles imposed on us by the Data Protection Act 2018 and UK GDPR.You have a right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.


    Name:


    Date:


    I declare that the above statements and particulars are true and constitute my fair presentation of the facts, and where the statements refer to my expectations and beliefs, such statements are made in good faith. I have made full enquiries and have not omitted or misstated any material facts which may be relevant to your consideration of this proposal form, and undertake to inform you of any changes to any material facts that occur prior to the point at which an insurance contract between us (if any) is agreed. I understand that the information I provide will be used by you to determine whether to provide insurance cover (and where you do decide to provide cover, to determine the price and terms of such cover).

    Please note that if you wish to submit your form by email, an indication of terms and conditions may be provided on the basis of this proposal form. 

    Agreeing to this form does not obligate you to accept any subsequent offer of an insurance policy.  We recommend that you keep a record of all information supplied to us, including copies of letters, emails, and this proposal form.