The information you provide below will be loaded into the SAFE Parliamentary Action Group Computer database it will enable us to produce more accurate statistics for the All Party Parliamentary Group on Financial Exploitation, MP’s, Treasury, The Various Governing Bodies and Media we are registered with the Information Commission and all details are treated as confidential.

Title:

Mr. Mrs. Ms Dr.

First name:

Surname:

Address Line 1:

Address Line2:

City:

County/State:

Postcode/ZIP:

Email:

Phone:

Fax:

Mobile:

My LLoyds No is:

Date Joined Lloyd’s:

i.e 01/01/1970

 Date resigned Lloyd’s:

i.e 01/01/1970

 Please tick as necessary

I am  an R+R acceptor   

I am a Hardship Name  

I am in litigation

Please state Cases, Numbers, Courts 

I have  been Bankrupted by Lloyd’s  

I do have an outstanding Equitas Judgment debt

Have you had a forced sale of Assets 

Approximate Loss incurred in monies paid to Lloyds

Additional Losses i.e.  Litigation etc

Total estimated Losses

Who is your MP/ Senator 

Have you contacted your Member of Parliament / Senator

Yes No

We will use your details as statistics for our reports to the: All Party Parliamentary Group / Treasury / Governing Bodies etc. 

Are you prepared to go Public

Yes No

Safe International Names Registration Agreement

All members who are registered hereby agree to waive any and all rights of access to the details of negotiations, documents and, minutes. Documents and data shall remain confidential and the property of Safe International Names.  Any developments that are not deemed confidential will be posted on the SAFE website.  We offer no guarantee that a satisfactory settlement can be achieved, only that we will use our best endeavors to do so, from our unique position.

The Registration fee is payable yearly and is non-refundable, the year starts from the date your signed registration is received and you cheque clears the bank, monies received help fund the work of SAFE including office and staff expenses.  I/we fully understand and sign to accept this agreement that I/we irrevocably undertake not to litigate against and will hold harmless any person or entity associated with SAFE and my/our registration or donation.

Please tick as appropriate

I/we fully understand accept  this agreement and to the terms and conditions stated above, I/we enclose our registration/ annual membership fee/fees (£50 /US$ 100 for each person registering)

*Please make cheques /postal orders payable to SAFE.

**For group registrations we require individual membership forms, but you can make a block payment.  

All donations are gratefully accepted, as we are not for profit organisation

Secretariat to the All Party Parliamentary Group Against Financial Exploitation

SAFE is a Company Limited by Guarantee Registered in England and Wales. No.4853224

Registered office 69 Sutton Road, Heston, Hounslow, London TW5 0PN

Tel: 0208 630 9990   FAX: 0208 630 9900   E-mails: elainewilliams_safe@blueyonder.co.uk 

Website: www.safe-online.org

Please return signed form with £50 (U.S.$100) Registration Membership Cheque’s or Postal Orders should be made payable to SAFE.

A receipt will not be issued unless requested.

Elaine Williams
Director SAFE
69 Sutton Road
Heston, Hounslow,
London TW5 OPN

*Also press submit button to send this copy to us