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RL360 - Full registration
1
About you
2
About your investment
3
Circumstances
4
Supporting documents
5
Consent to act
Full Name
*
First
Last
Phone
*
(incl country code)
Email
*
Your best contact email.
Date of birth
DD slash MM slash YYYY
Address
Your current residential address - PO Box addresses are NOT ACCEPTED.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Proof of ID
Please upload a photo or scanned PDF of your passport or driver's license as proof of ID.
Accepted file types: pdf, jpg, png, Max. file size: 512 MB.
Bond Ownership Name(s) (Individual Name(s) or Trustees
*
Is this a joint investment account?
*
Are there are two or more names on your policy?
Yes
Joint policyholder name
Is this a trust account?
Yes
Policy Number
*
Date of investment (if known)
MM slash DD slash YYYY
Which of the following fund(s) did you place in the bond?
select all that are relevant
Select All
Axiom Legal Financing Fund
LM Managed Performance Fund
All other LM Group funds including the Trilogy Wholesale FMIF
Premier Eco Resources
Premier New Earth (All Premier New Earth managed investment schemes)
Kijani Fund
EEA Fund Management (Guernsey) Ltd.
EEA Life Settlement Fund
EFG International Tracker Certificate on the A.C.A.C.I.A Index
Acacia 1 Natixis Autocall on Occidental Petroleum et al USD
Acacia 6 Natixis Autocall Note Linked to Standard Life Plc et al GBP
Acacia 4 Natixis Autocall on Deutsche Bank et al GBP
Acacia 7 Natixis Autocall Note on Royal Dutch Shell Plc et al GBP
Acacia 3 Natixis Autocall on Cisco Systems Inc et al USD
Acacia 9 Natixis Autocall on HSCEI Index et al USD
Standard Bank Fusion 1, 3 & 4
CitiFirst Autocall Nt Lkd 3 stks silver
Standard Bank Silver & Stocks USD
Any other failed fund(s) in your bond?
Total amount invested (in GBP or converted to GBP at £1 = USD$1.28 / £1 = A$1.85; £1 = €1.14 / £1 = US$1.28 / £1 = ¥140**
*
This is the total investment amount under this bond ownership name, including all failed funds.
Country of residence when you invested in bond
*
Name and contact details of advisory firm (IFA) through whom you invested
*
Please set out your understanding of the nature bond product at the time you invested in it.
For example, what was your understanding of the risks attached to the bond and the security of the product?
When did you first become aware that any or most of the value in your bond or the underlying funds had been lost? What triggered that awareness?
Have you previously been in correspondence with the bond provider about your loss?
*
Yes
No
Please provide details about any correspondence you have had with the bond provider
Have you previously investigated, or sought legal advice about, a legal claim against the bond provider?
*
Yes
No
Please provide details about the legal advice you sought
The redemption value of the bond was directly dependent on the performance of the underlying fund(s) selected. In other words, if the underlying fund(s) failed, this had a direct and immediate impact on the redemption value of the bond. Were you aware of this?
If yes, when did you become aware, and how? If no, what did you understand about the bond product and how it operated?
When the underlying fund(s) in which you were invested through the bond failed, did you think the value of your bond could recover by the time it would be redeemed?
If you had known the true nature and risks associated with the bond, would you have still invested in it?
*
Yes
No
Please explain what kind of product you would have invested in instead or how you would have used the money instead
Have you previously received any compensation in respect of your loss (e.g. from the English Financial Services Compensation scheme or any other similar compensation scheme)?
Yes
No
If yes, please provide details of the compensation received including the amount and entity from which you received it. Please upload any relevant documents that you have signed (such as an assignment of your rights to recover losses).
Please upload any documents such as valuations, dealing forms etc to support your claim.
TRUST ACCOUNTS: please also upload any deeds of trust or documents establishing or verifying your ownership of the bond Accepted file types: (PDF) only. Max file size: 32MB. Please contact us via admin@coburnci.com if you have trouble uploading your documents.
Accepted file types: pdf, Max. file size: 32 MB.
Any additional supporting documents
Accepted file types: (PDF) only. Max file size: 32MB.
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 512 MB.
Privacy
*
I agree to the following
I understand that my personal information is stored by CCI for the purpose of this group class action litigation.
I consent to CCI supplying my personal information to third parties in London or Isle of Man, such as the Legal Team, the litigation funder, the insurers representatives, administrators to return funds or any legitimate reason required for the purpose of the group class action.
I will provide any additional information or documents that CCI may reasonably require of you in order to pursue the Claim on my behalf.
Confirm that I will keep this communication and any information received regarding the conduct or progress of the Claim confidential.
I understand the authority and consents given in this form can be withdrawn at any time on written notice to Niall Coburn and CCI email admin@coburnci.com. Please note, a withdrawal after the Claim has been issued is likely to trigger obligations to pay costs incurred as more particularly explained in the Litigation Management Agreement.
Additional comments
Anything else we should know?
Referrer
*
Please select the name of the person who introduced you to this claim.
CCI
IFA
CAPTCHA
Click the checkbox below before submitting your claim.