Application Form. Centre and may affect the insurance premium. Version Page 1

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1 Application Form This application is for cover under the Professional Indemnity Insurance policy held by the National Pro Bono Resource Centre ( The Centre ) for approved pro bono projects. The form should be completed by the proposed supervising lawyer for the project. You must provide the information requested in the form and sign the declaration on the last page of the form. The information in the form will be used to determine whether the proposed project is eligible for professional indemnity insurance cover for the lawyers and paralegals who work on the project. Background The Centre has taken out an insurance policy with LawCover Insurance Pty Ltd ( LawCover ) that provides professional indemnity insurance ( PI ) cover for lawyers and paralegals carrying out or involved in legal services conducted with the approval of the Centre. A copy is attached ( The Policy ). Please read The Policy carefully as it includes terms and conditions including exclusions from cover. The Policy was taken out by the Centre to help in-house lawyers in corporations and government to undertake unpaid pro bono work on projects to be approved by the Centre. Accordingly, the Centre has paid the policy premium and there is no application fee or charge to be paid by the applicant. Also the Centre will pay any excess that is required to be paid in the event of a claim. The Policy is a safety net policy so cover will only extend to circumstances where there is no other professional indemnity insurance cover that applies to the pro bono project. You are required to provide details of any other insurance policy that may provide PI cover for work done on the project. The responsibility for coordination of each project will rest with a supervising lawyer. This lawyer could be in a pro bono clearing house, a law firm or in-house but must be the person who completes the Application Form. Responsibility for providing legal advice and holding appropriate practising certificates will rest with the particular lawyers providing the advice. Any person covered by the Policy has certain obligations and responsibilities which are set out in this Application Form and the Policy. Key amongst these are the obligation to notify of any claim or circumstance which could lead to a claim and co-operate with the insurer. The supervising lawyer must report to the Centre periodically the names of all lawyers and paralegals that have worked on any approved pro bono project and their pro bono hours worked 1. As these obligations will apply once the application is granted, you should read the Policy and if required take your own advice as to the protection it will afford to you before submitting the completed Application Form. 1 It is essential that accurate records of hours worked be kept as these are reportable to the Insurer by the Centre and may affect the insurance premium. Version Page 1

2 In order for a project to be approved by the Centre an Application Form must be submitted that complies and describes a project that will provide pro bono legal work as defined in the Policy (based on the Law Council of Australia 1992 definition of pro bono legal work) as follows: 1. A lawyer, without fee or without expectation of a fee, advises and/or represents a client in cases where: (i) a client has no other access to the courts and the legal system; and/or (ii) the client's case raises a wider issue of public interest; or 2. The lawyer is involved in free community legal education and/or law reform; or 3. The lawyer is involved in the giving of free legal advice and/or representation to charitable and community organisations. The Centre wants to encourage in-house lawyers to become involved in pro bono projects. The Policy will provide insurance cover, subject to its terms and conditions, for all lawyers and paralegals that have worked on an approved pro bono project provided their names are provided to the Centre as required. Version Page 2

3 APPLICATION Please complete the following details: 1. Name of Applicant.. N.B. This person must be the proposed supervising lawyer for the Project) and hold (or be eligible to hold 2 ) an unrestricted practising certificate in the jurisdiction where the legal work is to be done. 2. Contact Details of Applicant Address. Phone Number (0 ). 3. Name and Postal Address of Employer of Applicant. 4. Names of other lawyers who are proposed to be working on the Project (if known) Names of State(s) and/or Territories where the applicant holds a practising certificate. If none, please indicate eligibility to hold an unrestricted practising certificate Have you had ANY claim made against you for professional negligence for any prior pro bono legal work undertaken? YES/NO 7. Are you aware of any matters, circumstances or facts that may give rise to a claim for professional negligence against you for any prior pro bono legal work undertaken? YES/NO 2 2 This is to allow pro bono coordinators who are eligible to hold an unrestricted practising certificate to be the supervising lawyer but may rely on lawyers within their firm to provide the legal advice and hold the necessary practising certificate. Version Page 3

4 THE PROJECT 8. Is the project being conducted in conjunction with other parties or agencies? If so, please provide details of the nature of any such arrangements Name and description of the proposed pro bono project ( the Project ) (attach further detail if necessary) 10. Are any fees to be charged to the client for doing the pro bono legal work? YES/NO 11. Is there any other professional indemnity insurance policy that may provide cover for any aspect of the legal work to be done as part of the pro bono project. If yes, please provide name of insurer, policy number and period of cover. 12. Proposed start date of the pro bono project? 13. In what jurisdiction(s) is the pro bono legal work proposed to be performed? 14. Have you provided pro bono legal services in this/these jurisdiction(s) before? Version Page 4

5 DECLARATION I,, apply for the Project to be covered by the Policy and if the application is successful, I agree to: comply with the terms of the Policy keep accurate records of the names of all lawyers and paralegals who have worked on the Project and the number of hours each has spent doing pro bono legal work; and to advise the Centre as soon as practicable of: any change in the supervising lawyer for the Project. the names of each lawyer and paralegal who have worked on the Project and the number of hours each has spent doing pro bono legal work every three months from the date of approval of the project or as required. any written or verbal demand or claim alleging professional negligence arising from the provision of legal services provided within the ambit of the Project made against any lawyer or paralegal that has worked on the Project. becoming aware of any circumstance which could reasonably be expected to result in such demand or claim for negligence. the completion or close date of any approved Project after that occurs. Signed Date PRIVACY STATEMENT The National Pro Bono Resource Centre is committed to protecting the privacy of the information you provide to us. We need to collect the information requested on this form to enable us to ascertain whether you are eligible for professional indemnity insurance cover under the Policy. We may disclose the information we collect on this form to: Our staff involved in carrying out our functions Contractors engaged by us in carrying out our functions Law Cover in order to meet our obligations under the Policy Version Page 5

6 We may also disclose the names of the lawyers involved with the project, the names of their employers and the nature of the project through the Centre s publications including its website. By completing and returning this form you agree to us using and disclosing your information as set out above. If the information provided on this form is personal information, you can ask us what personal information we hold about you and where necessary notify us of any changes so we can ensure the information we hold about you is accurate, complete and up to date. This application form should be signed, dated and faxed to (02) or posted to The Director, National Pro Bono Resource Centre, Law Building, University of NSW, SYDNEY, NSW Version Page 6

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