QLP Limited. Clinical Negligence Disbursement Funding. Application Form

Transcription

1 QLP Limited Clinical Negligence Disbursement Funding Application Form

2 Notes: In completing the form, please complete as much as possible but if accurate facts and figures are not available, reasonable estimation would help us but please make it clear where such estimations have been used. 1. Firm Details Firm name Firm Status If LLP or company, registration no: Main Office Address Tel Fax DX No of Partners No of Offices SRA Number LEXCEL Accredited FCA Exempt Professional Yes/No Firm EPF Number

3 2. Clinical Negligence Supervision Throughout this form Partner includes member of LLP or Director of Limited Company. Please provide the name of the partner with overall responsibility: Partner Phone Primary Contact Phone No of Clinical Negligence Partners No of Clinical Negligence Solicitors Other Clinical Negligence Fee Earners 3. Memberships Please provide details of the firm s relevant panel memberships: AVMA APIL Law Society Clin Neg Panel

4 4. Regulation & Training Please confirm that you comply with all relevant SRA regulations in the following areas. FCA Data Protection Money Laundering Complaints Procedure 5. Clinical Negligence Claims CURRENT ARRANGEMENTS Current LEI Insurer Typical current ATE Limit of Indemnity per policy Is insurance incepted at same time as CFA? If no, when? Do you have delegated authority? How are client s disbursements funded? Current total incurred disbursements for all cases Average disbursements per claim

5 REQUIREMENTS IN NEXT 12 MONTHS: Estimated new instructions Of which how many will have quantum 50,000 +? Total estimated disbursement funding needed Estimated amount of funding per claim ATE cover needed per client Do Counsel s fees need to be insured? Is ATE required for investigation costs? If yes, how much? What do you need funding for: Expert Reports Court Fees Counsel s fees

6 6. Risk Assessment What is your risk assessment policy for new cases? What is your risk assessment process for on-going cases?

7 7. Clinical Negligence Conditional Fee Business Year Prior Prior -1 Prior -2 Avg. Damages CFA Case Experience Case Numbers Open Won Lost Discontinued Own Disbs. Costs Incurred on Unsuccessful Cases Other sides costs 8. Clinical Negligence Business Sources Please confirm your business sources. Method Yes No % of Total CFA Cases Local/ national reputation Word of Mouth referrals 3 rd Party Referrals Newspaper advertising local Newspaper advertising national Radio advertising local Radio advertising national TV advertising local TV advertising national

8 Total 9. Compliance Has any partner of the firm been convicted of any criminal offence other than minor motoring offences? Yes / no If yes please provide details. Have any solicitors currently or previously been subject to disciplinary procedures by the Office of the Supervision of Solicitors or Law Society? Y/N 10. Declaration If yes please provide details. DATA PROTECTION NOTIFICATION In accordance with the provisions of the Data Protection Act 1998, any personal or sensitive data supplied to QLP Limited will be held in a secure database and used solely for the purpose of this application. This information may be forwarded to an appropriate third party but solely for the purposes of processing this application. DECLARATIONS I/We declare that the information given in this application is true and complete and I /we agree that this shall be the basis of any agency agreement. I/We understand that if any of the information is found to be untrue, that the agency can be terminated at the sole discretion of QLP Limited. I / We declare that QLP Limited will be advised promptly, in writing: 1. of any change of address; 2. of any changes of Directors, Controllers, Principals or Partners; 3. in the event of the Agent becoming bankrupt, insolvent, going into liquidation, entering into an agreement with any creditors or receivers being appointed; 4. of any changes of the capital structure of the business; 5. if any Partner, Director or Controller of the Agent is or becomes subject to disciplinary proceedings instituted by a professional or similar body; 6. of any convictions for Criminal offences (other than motoring offences) of any Director, Controller, Principal or Partner occurring after the date of this Application;

9 7. if any agency appointment with another Insurer is terminated; 8. if any registration under the FCA or membership of a professional body is terminated. I/We also declare to maintain in force professional indemnity cover. I/We understand that QLP Limited may take up references in connection with the application. I/We understand that completion of this document does not constitute the granting of an Agency with QLP Limited. I/We further understand the granting of an Agency is subject to both parties signing and dating the Company's Terms of Business Agreement which will be received from the Company upon it accepting this application. Signed: Name: Position: Date: