Personal Injury /Clinical Negligence After-The-Event Insurance Proposal Form

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1 Personal Injury /Clinical Negligence After-The-Event Insurance Proposal Form Clients Details Client First Name Client Surname Litigation Friend Telephone Number Fax Number Date of Birth Is it likely that an application for security of costs will be made against the proposer? Is the proposer aware of any other insurance which may be relevant to this dispute? Is the proposer, or has the proposer ever been insolvent or been made bankrupt or discharged from bankruptcy in the last 5 years, or been a director of a company which has been declared insolvent in the last 3 years? Has the proposer been convicted of a criminal offence (other than motoring offence not resulting in imprisonment)? Solicitors Details Firm Name Solicitor Dealing Reference Date instructed DX

2 Telephone Number Fax Number Your Own Counsel Name Chambers Opponent Details Company Name Contact Name & Position Telephone Number Fax Number Legal Status: Private Limited Company Limited Liability Partnership Nature of Business Quoted Company Public Company Sole Trader Partnership Are they registered for VAT? VAT Number: Please explain why you consider that the opponent will be able to pay damages & costs? If the opponent has insurance please provide the name of the insurer: Please provide details of any additional parties who have been, or may be joined by the opponent in legal action Opponents Legal Representatives Law Firm Partner Dealing Counsel Chambers Conditional Fee Agreement Are you acting under CFA? Is the CFA Full or Partial? Date of CFA Likely Success Fee of Appointed Solicitor % % Percentage if partial:

3 Please confirm Counsel is on a CFA Do you know if the opponent s legal representatives are acting under a CFA? Is their CFA Full or Partial? Date of CFA: Case / Legal Action Type of Case: Accident at Work Clinical Negligence Other RTA Slip / Trip Please Specify: Please provide a brief summary of the dispute including dates / amounts in dispute / remedies required: Date of incident When were you instructed? What stage has the legal action reached? Pre-action protocol response provided Trial Date Set Proceedings issued If Proceedings have commenced please state: Court Name: Claim Number: Current Stage of Proceedings: Likely Date of Trial: Time Estimate: If Proceedings have not yet commenced please state: Court Name: Claim Number: Current Stage of Proceedings: Likely Date of Issue: Likely Date of Trial: Time Estimate: % Public Liability Industrial Disease Percentage if partial: Pre-letter before action Particulars of claim served Letter before action sent Defense received Has Liability been admitted? Date: Have you complied with any pre-action Protocols? Please identify the tribunal for the legal action: / Not Yet Applicable Divisional Court

4 Arbitration Technical & Construction Court County Court Commercial court, Admiralty Division Queens Bench Division Commercial Court House of Lords Court of Appeal Chancery Division Prospects of success? 51-60% 61-70% 71-80% 81-90% % Are you claiming or defending? Has a defense been received? Please provide details about any negotiations or ADR attempts: Please provide details of any Part 36 offers or settlement proposals to date Please provide details of any likely counterclaim: Please provide details of main arguments against legal actions which might be used by the opponent: Has an Expert been appointed? If an Expert has to been appointed, please identify the disciplines and provide copies of any reports: If an Expert has yet to be appointed, please provide a description of the expertise that may be sought: Evidence Please advise on the complexity of the legal issue Highly Complex Fairly Complex Straightforward Complexity of the Evidential Issues Highly Complex Fairly Complex Straightforward Type of evidence required Oral & Documentary Oral Documentary

5 Cost Information Costs to Date Cover Required? Estimated future costs to and including Trial? Cover Required? Own Solicitors Fees Own Disbursements Own Counsel s Fees Opponent s Costs & Disbursements Taking into account, please confirm the total amount of funding and cover required: Quantum Please provide value of damages claimed Is there likely to be a Counterclaim? If YES, please provide details Claims Track Fast Track Multi Track Please provide the value of the claim: What is the realistic value of settlement? What do you think are the prospects, in percentage terms, of achieving this? How has the claim been quantified? Indemnity What level of indemnity is required? What excess is required? If you require top up insurance, please advise what level of indemnity you currently hold? Does the insured have BTE Lei Cover or TU Membership? If yes, please provide reason for ATE Cover % Has a proposal regarding this matter been made to any other broker or insurer? If yes, please provide details of outcome of applications

6 If indemnity requested is over 100K: What is the claimant s financial position? What is the estimation of expert fees to end of trial? How settled are the legal authorities on this case? For what period will interest run on damages? What rate of interest will apply? Can you confirm the experience of expert involved? What is the solicitor s view of overall likelihood of settlement before trial? Is the realistic value of settlement inclusive of interest & costs? Additional Documentation Please tick if attached, or advise if applicable, but not yet obtained: Counsel s Advice Witness Statement Pleadings Letter of claim Correspondence Other Documents Please provide any other additional information which may assist us in the underwriting decision:

7 Data Protection Act I/We understand that Shire & Co Legal Services Limited may use any of the information 1/we supply for the purposes of underwriting and administering a policy. Any of the information I/we supply may also be used for dealing with any claims on a policy or any other similar activity. I/We agree that any information I/we supply to Shire & Co Legal Services Limited may be sent to lawyers, medical agencies or other experts, any court, tribunal, loss adjusters or brokers or any other party associated with Shire & Co Legal Services Limited. I/we agree that I/we may be contacted from time to time by Shire & Co Legal Services Limited for updates on my claim. If you wish to see a copy of the information we hold on you then you can write to Shire & Co Legal Services Limited, 1 Calico Business Park, Sandy Way, Amington, Tamworth, Staffordshire B77 4BF. Declaration I declare that the information contained in this form and accompanying enclosures is true to the best of my knowledge Signed Print Name Date This form should be completed and signed by you, the solicitor. It should then be sent, along with copies of all supporting documents either by or in hard copy to Shire & Co Legal Services Limited, 1 Calico Business Park, Sandy Way, Amington, Tamworth, Staffordshire B77 4BF Completion of this form does not mean that insurance cover is in place. Non-Disclosure or misrepresentation of any material fact may invalidate any insurance policy.

(1) Appointed Solicitors Details. Address DX Box. (2) Insured s Details. If appropriate. Address. Postcode

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