ONE OFF CASE APPLICATION FORM
Please note: Completing this form does not guarantee that insurance will be offered nor does it
bind you, Client Cover or any insurer into a contract of insurance. Should terms be offered you
will receive a formal quotation and acceptance pack including a statement of demands and needs
and also the relevant policy wording.
You must disclose all material facts which relate to this case. If you are unsure as to whether a
fact is material you should disclose it.
Section 1: Solicitor contact details
Solicitor firm name
Office / building name
Solicitor firm contact
Solicitor email address
Solicitor phone number
Solicitor fax number
Client cover use: EPF register number
If this is your first submission to us in general or your first submission to us for this type of case
please complete the track record summary at the end of this proposal form.
Section 2: Claimant proposer details
Claimant proposer name
Office / building name
Claimant status (Company, Individual,
Section 3: Opponent details
Office / building name
On what basis are you certain that the
opponent has the finances to meet
damages or costs? Please continue on a
separate sheet if necessary
Section 4: High level case summary
Please choose from one of the following case types: RTA, EL, PL/OL, RTA damage
only. Other personal injury (please specify)
Case type (from list above)
Date of incident
Case track Fast Multi
Date CFA entered into (if already)
Proposed success fee %
Is counsel on a CFA? Yes No
Solicitors view on prospects %
Counsels view on prospects %
General damages £
Special damages £
To date costs to conclusion
Own costs £ £
Own disbursements excluding counsel £ £
Own counsels fee £ £
Opponents costs and disbursements £ £
Total level of cover required £
Section 5: Current position on the case
Please tick the appropriate boxes with regards to this case
Is liability admitted? Yes No
Is liability denied? Yes No
Offers of settlement made or received? Yes No
Have proceedings been issued? Yes No
Has defence been received? Yes No
Trial date been set / window allocated? Yes No
Has any solicitor discontinued case? Yes No
Has any solicitor rejected this case? Yes No
Other Solicitor not taken on a CFA? Yes No
Any level of BTE insurance in place? Yes No
Any insurer declined to offer cover? Yes No
If you have answered yes to any of the questions above please provide additional details on a
separate sheet. If your client has any BTE (Before The Event) cover in place please provide
details of the level of indemnity and a copy of the policy wording.
Section 6: Mandatory Enclosures Checklist
You must provide the following enclosures with your application
Case summary e.g. letter of claim
Any response from opponent
Details of offers made or received
Counsels advice or an executive email summary of prospects from counsel
Other relevant expert reports / Witness statements
Section 7: Other Enclosures
Please tell us which other enclosures you are able to provide and have enclosed. Please note the
more detail you are able to provide the easier insurers will find it to evaluate where After the
Event cover can be offered.
Any details with regard to other insurances such as BTE
Should you be waiting to secure After The Event Insurance prior to entering into a CFA we will
require a copy of the signed CFA before cover can be incepted.
Section 8: Proposer and Solicitor Declaration
We are aware that the information in this application form will form the basis on which insurers
will evaluate whether After The Event insurance cover can be offered and will form the basis of
the contract between the insurer and the insured. We confirm that to our knowledge and belief all
information in this application and associated enclosures is true and accurate.
Signed (Solicitor) Date
Signed (Proposer) Date
If this is your first submission to us in general or your first submission to us for this type
of case please complete the track record summary on the following page.
You can email a scan of your application to email@example.com or please send your original
completed form and enclosures to:
9 Breary Lane
Section 9: Solicitor Firm Summary
Please tell us a little bit more about your firms CFA track record for this type of case.
How many CFA cases which fall under the same category as
this application has the firm handled in the last two years?
In how many cases were damaged recovered?
How many cases remain outstanding
How many cases did not result in an entitlement to damages or
recovery of a success fee
Please tell us a little more about your areas of practice:
What percentage of your fee firm’s income relates to?
Other work areas
Has the firm has any professional Yes No
indemnity claims against it which relate to
litigation work in the last 3 years?
Has any Partner or Solicitor in the Yes No
department relating to this application had
conditions imposed on their practising
Has the firm being subject to a Law Yes No
Society or SRA investigation other than a
monitoring visit in the last 6 years?