Tripemco Burlington Insurance Group Limited
c/o 99 Highway #8
Stoney Creek, Ontario L8G 1C1
Toll Free: 800-373-1106
Errors & Omissions Renewal Application for Paralegals
Current Policy #
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.
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.)
List ALL Office Locations
Please indicate the Applicant's gross annual revenue:
(i) Prior Policy Period:
(ii) Current Policy Period:
What percentage of fees over a 12 month period are earned from SABS related work:(Auto Accident Benefit Claims)
Complete the following for ALL licensed paralegals (including applicant) to be insured under this policy:
Years of Experience
Does the applicant and paralegals listed in question 5 belong to any professional associations:
If yes, list such associations and provide membership number:
Have any of the individuals listed in question 5 ever been investigated or charged with a criminal act?
If yes, please provide details:
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?
If YES, please give details:
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?
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.
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)
I require a limit of: $
Please note that the proposed insurance will be effective at a date determined by the insurers.
Provide details of any material changes in the applicant's operations in the past 12 months.
DECLARATIONS AND SIGNATURE
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.
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:
Partnership or Joint Venture
Contents and Office Equipment (excludes earthquake, flood, and sewer back up)
$1,000 per claim
$1,000 per claim
List all locations at which business is conducted, providing details indicated below.
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.
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.