Tripemco Burlington Insurance Group Limited
c/o 99 Highway #8
Stoney Creek, Ontario L8G 1C1
Telephone: 905-333-3076
Facsimile: 905-333-4904
Toll Free: 800-373-1106
 

Errors & Omissions New Insurance Application for Paralegals

 THE APPLICANT
Please answer ALL the questions. This information is required to make an underwriting and pricing evaluation. If a policy is issued it will be issued in a reliance on the answers provided below. If a question is not applicable, state "not applicable" not "N/A." If more space is required to answer a question, continue on applicant's letterhead. The application and any supplement(s) must be signed and dated by a principal, partner, or officer of the prospective insured's organization.
1. Name of Firm:
If more than one legal entity, please indicate the relationship between each:

(Please note that an insurance policy cannot be shared unless there is a financial interest.)
2. Website Address (if applicable): http://
3. Mailing Address:
4. List ALL Office Locations:
5. Date operations began:
6. (a) Please indicate the Applicant's gross annual revenue:
  (i) Prior Policy Period: $
(ii) Current Policy Period: $
6. (b) What percentage of fees over a 12 month period are earned from SABS related work:(Auto Accident Benefit Claims) %
7. What risk management practices are employed by your firm to avoid E & O claims:
8. Complete the following for ALL LICENSED PARALEGALS (including the applicant) to be insured under this policy:
Name Duties/Title Education Years of Experience
9. Does the Applicant belong to any professional associations: Yes No
  If yes, list such associations and provide membership number:
10. Have any of the individuals listed in question 8 ever been investigated or charged with a criminal act? Yes No
  If yes, please provide details:

 INSURANCE COVERAGE
11. (a) Has the Applicant ever previously purchased professional or errors and omissions liability insurance? Yes No
11. (b) If yes, please give the following details for the last three years:
  Insurer Period   Expiring Premium   Limit   Deductible
$ $ $
$ $ $
$ $ $
IF YOUR HAVE CONTINUOUS COVERAGE WITHOUT ANY LAPSE, PLEASE PROVIDE A COPY OF YOUR CURRENT POLICY OR CERTIFICATE INDICATING YOUR "RETROACTIVE DATE" TO ENSURE THAT THIS DATE IS CONTINUED.
12. Has any policy of or application for similar insurance on your behalf or on the behalf of any of your principals, partners, officers, employees, or on behalf of any predecessors in business ever been declined, cancelled, or renewal refused? Yes No
If YES, please give details:

 Loss Experience
13. (a) In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbally? Yes No
If YES, please give details:
13. (b) Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above? Yes No
If YES, please give details:
WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, IT IS AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.

 LIMITS REQUEST
14. Please select the amount of Errors and Omissions Insurance coverage you require

$1,000,000 limit with a $2,000,000 aggregate limit (this is the minimum limit required by the Law Society of Upper Canada)
OR
I require a limit of: $

Please note that the proposed insurance will be effective at a date determined by the insurers.

 BUSINESS PRACTICE
15. (a) Were more than 50% of your total gross billings for any one year derived from a single client or contract? Yes No

If Yes, please provide:

a) Client Name
b) Services rendered
c) How long do you expect this relationship to continue
15. (b) Does your firm secure a standard written contract or retainer agreement for every project? (Please attach a sample copy)
Yes No

If yes:
a) Provide the percentage of your revenue where a written contract is secured. %
b) Do your contracts contain any of the following: (check all that apply)
Hold harmless or indemnification clauses in your favour?
Hold harmless or indemnification clauses in your client's favour?
Guarantees or warranties?
A specific description of the services you will provide?
Payment terms?


 DECLARATIONS AND SIGNATURE

NOTICE:

This is an application for CLAIMS-MADE & REPORTED INSURANCE. Such insurance applies only to claims that are first made against you and reported to the Insurer in writing during the policy period, any subsequent renewal of the policy or any extended reporting period and may additionally limit coverage applicable to acts, errors, omissions or offenses made prior to the inception of the policy period. The limits of liability are reduced by amounts paid for legal defense and such payments for legal defense are applied against the deductible amount.

Optional Coverages

The following coverages are now available with your Errors & Omissions Liability policy.
If you would like us to provide a quotation please check the applicable boxes and complete the required information.


THIRD PERSONS BOND (Coverage to protect your client fees from theft by an employee in your office)



COMMERCIAL GENERAL LIABILITY

Limit: $1,000,000 occurrence
Deductible: $2,500 per paralegal firm


Form of Busines: Individual Partnership or Joint Venture Coorporation

PROPERTY COVERAGE
Contents and Office Equipment (excludes earthquake, flood, and sewer back up)
Limit:
Deductible:
$10,000
$1,000 per claim
Limit:
Deductible:
$25,000
$1,000 per claim

List all locations at which business is conducted, providing details indicated below.
Location/Address Occupancy Square Meters Owned/Leased

Our Privacy Policy and Commitment to Protecting Your Privacy

Tripemco Burlington Insurance Group Limited values you as a customer and we thank you for your confidence in choosing our company to place your insurance with one of our approved insurance companies. As a policyholder, you trust us with your personal information. We respect that trust and want you to be aware of our commitment to protect the information you share with us in the course of doing business with us.

How We Use and Disclose Your Information

When you purchase insurance from us, you share personal information so that we may provide you with the products and services that best meet your needs and provide the insurance protection you have requested. In order to do this, we may use and disclose your personal information to:

� Communicate with you.
� Assess your application for insurance including underwriting and pricing your policies.
� Evaluate claims.
� Detect and prevent fraud.
� Analyze business results.
� Act as required or authorized by law.

We assume your consent for our company to use this information in an appropriate manner. All personal information is safeguarded with appropriate security measures.

What We Will NOT Do With Your Information

We do not sell customer information to anyone. Nor do we share customer information with organizations outside of our associated companies.

We Strive to Protect Your Personal Information

All employees, agents, independent brokers and suppliers who are granted access to customer records understand the need to keep this information protected and confidential. They know they are to use the information only for the purposes intended. This expectation is clearly communicated and reinforced. We have also established physical and systems safeguards, along with the proper processes, to protect customer information from unauthorized access or use.

Your Privacy Choices

You may withdraw your implied consent at any time (subject to legal or contractual obligation and on providing us reasonable notice) by contacting our Privacy Officer. Please be aware that withdrawing your consent may prevent us from providing you with the requested product or service.

If You Need More Information About Our Privacy Policy

For more information about our privacy policies and procedures, please contact our Privacy Officer:

Tripemco Burlington Insurance Group Limited
99 Highway #8
Stoney Creek, Ontario L8G 1C1
Telephone: 905-333-3076
Facsimile: 905-333-4904
Toll Free: 800-373-1106

Kelly Watters, RIBO, CAIB
kwatters@tripemco.com
Royal and Sun Alliance Insurance Company of Canada
Attention: Claims Department
18 York Street, Suite 800
Toronto, Ontario M5J 2T8
Fax: 416-682-9213
Telephone: 416-366-7600

Ian Fraser
AVP | ProFin
Global Specialty Lines
ian.fraser@rsagroup.ca

SIGNATURES AND ACKNOWLEDGEMENTS

Applicant acknowledges receipt of and agrees to the Privacy Disclosure and Consent provisions contained in this form.

I hereby declare that the above statements and particulars are true and that we have not suppressed or misstated any material facts and we agree that this application and its supplements shall be the basis of the contract with the Insurer. It is understood and agreed that the completion of this application and its supplements does not bind the company to sell or the applicant to purchase the insurance.

Contact Name:
Company Name:
Company Address:
Company Phone:
Company Fax:
Company E-Mail:
Name of Applicant:
Home Address of Applicant:
Home Phone Number of Applicant:
Cell Phone Number of Applicant:
E-mail address of Applicant: � A confirmation e-mail will be sent to this address.
The name, phone number and e-mail address of the Applicant must be of the individual paralegal, not the entity.
Terms of Application: By sumitting this form, I agree to the terms of this Application.