Application Form

Name of applicant (or name of legal person filing the application) (*):

On behalf of whom do you file the application? (In case the application is filed on behalf of another legal or natural person attach a power of attorney):

Address (P.O. Box or street and number) (*):

Postal code (*):

City/village (*):

District (*):

Country (*):

Telephone No (*):

Fax:

E-Mail Address:

Identity Card / Passport No. (or registration number of legal person) (*):

Social Insurance No. (for natural persons only):

Against which ICF member do you submit this application?

CIF Name:

Client Code:

Investment Account Number:

Provide a brief description of your claim

Description:

(Attach copies of all relevant documents, such as a copy of the covered services agreement, the type and amount of alleged claims, a description of the facts and evidence with specific references to actions or omissions of the ICF member, any other evidence or supporting documents and copies of any correspondence with the ICF member concerned)

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Have you already contacted the ICF member against whom this application is submitted?

If yes, what was their response?:

(Attach copies of all relevant documents / supporting evidence)

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Is your application the object of any court proceedings? If yes, provide details and evidence on the case

Description:

(Attach copies of all relevant documents / supporting evidence)

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INVESTOR COMPENSATION FUND (I.C.F)