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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 Street Town Postcode Solicitor firm contact Solicitor email address Solicitor phone number Solicitor fax number Partner responsible 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 Street Town Postcode Claimant status (Company, Individual, Executor) Section 3: Opponent details Opponent name Office / building name Street Town Postcode 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 £ Maximum estimated 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. Pleadings 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 firstname.lastname@example.org or please send your original completed form and enclosures to: ATE Applications Client Cover 9 Breary Lane Leeds LS16 9AD 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? Commercial litigation Non-commercial litigation 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 certificate? Has the firm being subject to a Law Yes No Society or SRA investigation other than a monitoring visit in the last 6 years?
"ATE insurance - Personal Injury Application"