Personal Injury PROPOSAL FORM

Personal Injury PROPOSAL FORM

Personal Injury PROPOSAL FORM IMPORTANT NOTES: The completion of this Proposal does not in itself bind either the Insurers or the Proposer to any contract of insurance. It is important that all questions are answered accurately and that all relevant information that may affect the Insurer s decision to accept insurance or the terms of the insurance must be disclosed. Failure to do so may invalidate the Policy. In the event of a Policy being issued pursuant to this Proposal this Proposal shall constitute part of the Policy. This Proposal form shall be completed jointly by the Insured and his/her Legal Advisers and both shall sign the respective Declarations where indicated. Legal Representative of Solicitor firm DX Solicitor reference Telephone number email Fee earner acting Supervising solicitor s name if different Proposer (claimant) Legal Status: Individual / Trustee / Liquidator / Limited Company/ Plc / Partnership/ Other (please state below) Age The Defendant Legal Status: Individual / Trustee / Liquidator / Limited Company/ Plc / Partnership/ Other (please state below) Business or trade Solicitor s name and address (if known) Insurer (if known) * PLEASE NOTE: YES OR NO (shown as Y / N) and multiple choice responses should be circled in black or blue pen

The Legal Action Type of case: RTA / Industrial Disease / Clinical Negligence / Employers Liability / Public Liability - Slipper or Tripper / Other (please state): Insolvency / Excess of Loss (please use box at right) Date of incident Claims Track Date of first instruction Fast / Multi Quantum estimates General damages Special damages Liability admitted? Y / N If yes is this subject to any caveats? Y / N Proceedings issued Y / N Defence received? Y / N Part 36 offer received Y/N Part 36 payments Y / N Trial date Set? Y / N Estimated date Is defendant insured? Y / N If defendant is insured, who is the insurer? How has the case been funded to date? Legal Aid / BTE / Private retainer/ CFA / Solicitor funded / Other (state below) Prospects of success - Minimum 51% - (State %) % Is the case being run under a Conditional Fee Agreement (CFA)? Y / N Date of CFA Date of first instructions Has counsel entered into a CFA? Y / N Have checks been made to establish if Before the Event (BTE) legal expenses cover is available? Y / N If BTE cover exists please advise reason for seeking this insurance: Claimant estimated costs Own Solicitor s fees Counsels fees Other disbursements TOTAL In order for Insurers to assess the case please enclose all relevant documentation supporting it, providing an overall view of the case to date, including a description of the accident, details of injuries sustained and issues in dispute. Please also include witness statements, a note of the relationship if any between any of the witnesses and the Proposer, photographs where relevant and any Statutory Defence. Please list attachments to this application here: Opponent estimated costs Limit of indemnity (cover limit required - minimum 10,000) NB The Sum Insured selected should be at least sufficient to cover the Opponents Legal Costs and Disbursements and your client s own Disbursements to take the matter to trial. Summary of the Facts of the Case

General questions Has the Solicitor or anyone in the solicitor firm had any business or personal relationships with the client prior to receiving instructions on this case? Y / N Has this case been proposed to or declined by any other insurer? Y / N If Yes please give details below: Declaration by Proposer 1. I/We declare that the contents of this Proposal Form are true to the best of my/our knowledge and belief and agree that the contents of the Proposal Form will be the basis of the Policy of Insurance and that any non-disclosure of any relevant information may invalidate the Policy of Insurance. 2 I/We authorise the Legal Representative to provide the Insurers and their representatives all such information as they may require and I/we agree that the Legal Representative may give information to Insurers notwithstanding that this would otherwise be in breach of privilege and confidentiality owed to me/us. 3 I/We understand that the Insurer will use any information that I/we supply for the purpose of administering and underwriting this policy/scheme. It will also be used, if required, for the purpose of dealing with claims, for giving advice and assistance, and to update Insurer records. I/We further agree that information may be sent outside of the Insurer for the same purposes. The information may be sent to lawyers and other experts, to a court or tribunal, insurance intermediaries or insurance companies, and other specialists or providers of services to the Insurer. 4 I/We consent to information being sent outside the European Economic Area (such as the Channel Isles or the Isle of Man) if necessary for dealing with this policy/scheme. 5. I/We agree to the Legal Representative giving the irrevocable undertaking set out in the Declaration below. Signed (BLOCKS) Date Declaration by Legal Representative 1. I declare that the information set out above is true to the best of my knowledge and belief. 2. I warrant that the Proposer has at least the prospects of success in the Legal Action indicated above. 3. If a policy is issued by the Insurers, then I irrevocably undertake that I will immediately advise the Insurers in writing of: a) The issuing of proceedings b) Trial date and estimated length of trial; c) Conclusion and/or discontinuance of the matter; d) Part 36 offer or payments by defendants. e) The discovery by whatever means of any fact or evidence or other matter that materially affects the Proposer s prospects of success in the Legal Action; f) Any failure by the Insured to provide instructions or otherwise co-operate in the conduct of the Legal Action, or any requirement by the Insured for the case to be conducted unreasonably or so as to incur an unjustifiable expense. 4. I believe that the Sum Insured selected above is sufficient to pursue the case to trial. COVER WILL NOT START UNTIL INSURERS HAVE ACCEPTED THE PROPOSAL AND THE PREMIUM HAS BEEN PAID/AGREED TO BE PAID. OFFICE USE ONLY Signed Position Date

WRITE ADDITONAL NOTES ON THIS PAGE, PLEASE Now please send this completed form to the address below together with all other related documents. For additional information regarding this, kindly write to: dib insurance The Old Glove Factory Bristol Road Sherborne Dorset DT9 4HP, or call 01935 389812. email info@dibinsurance.com or see www.dibinsurance.com insurance dib insurance is a trading name of Straight Solutions Ltd, an insurance intermediary regulated by the FSA (FSA number 315448). Members of The British Insurance Brokers Association