Professional Indemnity Insurance (Lawyers) Proposal Form ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed by the provisions of the UAE Federal Law No. (6) of 2007 Establishment of the Insurance Authority & Organization of its Operations, with Registration No. (1). Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any. You must provide full, accurate, and true answers to all questions listed below. Material facts which you know or ought to know should be fully and accurately disclosed. Failure to do so may result in rejecting your claim and/or terminating the insurance policy from inception. If you are in any doubt about what you should disclose, please do not hesitate to contact us. A material fact is one that would influence our decision whether to offer you insurance or the terms which we offer. If the space provided is inadequate, please provide details using an additional information sheet, signed and dated. Your insurance does not commence when you sign the proposal. Your cover will only commence once we have reviewed the proposal form and confirmed cover in writing. Please keep a copy of this proposal form for your record along with any correspondence/ information provided to us and policies/endorsements that are issued to you subsequently. 1/7
1. General information a. Name of the firm: b. Address of head office: (Please show the address required on the policy) P.O. Box: Country: Phone number: Fax number: City: Mobile number: Email address: Website address: c. Address of branch office(s) and name(s) of resident partner(s): d. When was the firm established? e. During the past five years, has the name of the firm been changed or has any other firm purchased or any merger or consolidation taken place? Yes No If so, please give full details: f. Member of Association? Yes No g. Details of all practicing principals or partners Names Qualifications, dates qualified/total duration of professional experience Position held in company and how long 2/7
1. General information (continued) h. Total number of principals, partners and staff Technical: Number Principals, partners or officers Lawyers and legal assistants Staff other than typists and office staff (please specify) Typists and office staff i. Does your firm, any partner, principal or staff manage, own or have financial control of any bank, trust company, mortgage or loan association, title guarantee or real estate company or undertake work as executor, trustee, director or company secretary? Yes No If so, please give full details: 2. Nature and volume of your present and foreseeable future activities a. Describe your firm by showing the percentage of gross fees to be received from the following activities during the current fiscal year i) Litigation % ii) Real estate conveyancing % iii) Estate work % iv) Corporation Law % v) Patents % vi) Commercial matter % vii) Others (please specify) % 3/7
2. Nature and volume of your present and foreseeable future activities (continued) b. Does the firm s practice extend or has it ever extended to activities abroad? Yes No If so, please indicate: i) In which countries and the respective share of total business: ii) Method of handling such business: c. Fees Please indicate your fiscal year: What are the gross fees for: i) Last fiscal year? ii) Current fiscal year (estimate)? iii) Next fiscal year (estimate)? 3. Previous insurance/previous claims a. Have you previously been insured? Yes No If so, please specify: Name of Insurer Policy Period Limit of Indemnity 4/7
3. Previous insurance/previous claims (continued) b. Has your previous application been declined? Yes No Has your previous insurance i) Required increased premium? Yes No ii) Required special restrictions? Yes No iii) Been terminated/not been renewed by an insurer? Yes No If so, please give detailed information: c. Have any claims been made during the past five years against your firm? Yes No If so, please give details of paid claims including quantum and background of each claims: d. Is your firm aware of any circumstances or incidents which may result in a claim against your firm? If so, please give details: Yes No 4. Indemnity required a. Limit any one claim: b. Aggregate limit: c. Deductible each and every claim to be borne by the insured: 5/7
5. Endorsements to basic cover a. Extended claims reporting period Yes No b. Loss of documents Yes No If so, up to what amount? c. Incoming/Outgoing partners i) Incoming partners Yes No ii) Outgoing partners Yes No If this extension is required, please advise the names of the partners and incoming/outgoing dates: d. TPL Yes No If so, up to which limit of indemnity? 6/7
Declaration I/We hereby declare that the statements/information given by me/us in the Proposal Form are full, accurate and true. It is hereby understood and agreed that the statements, answers and particulars provided in this Proposal Form and as per the attachments are the basis on which the insurance policy is being issued/effected. If after the insurance policy is effected, it is found that any fact in the statements, answers or particulars in this Proposal Form is incorrect, untrue, inaccurate, misrepresented or non-disclosed in any material respect, ADNIC shall have no liability under the insurance policy and/or shall have the right to terminate the insurance policy from inception. Name of Proposer: Title: Signature: Stamp: Date: Note: Please note that each page of the proposal form should be signed by the Proposer or its legal representative 7/7