Afterthe Event SchemeApplication Form
FirmDetails1. Firm Name:
2. Firm Status:
3. Nameof AdministrationContact:
4. AdministrationAddress:
5. EmailAddress:
6. Website:
7. TelephoneNumber:
8. FaxNumber:
9. DXNumber:
10.TotalPartnersin theFirm:
11.Numberof Offices
Please Select
12.Pleaseprovidedetailsof feeearningstaffthatwillhaveconductof casesinsuredbyARAG:
Name / JobTitle / EmailAddress
Compliance
1. LawSocietyRegistrationNo:
2. FCARegistrationNo:
3. Haveanyof thepersonslisted beenconvictedof anycriminal offenceotherthanminormotoring offences?
Ifyes pleaseprovidedetails:
4.Haveanysolicitorscurrentlyor previouslybeensubjectto disciplinaryproceduresbythe OfficefortheSupervisionof SolicitorsorLawSociety?
Ifyes pleaseprovidedetails:
5. Areanysolicitorsorpartnersin thefirm subjecttorestrictionson their PracticingCertificate?
Ifyes pleaseprovidedetails:
Please Select
(Note:youarenot required toinclude convictions regardedas "spent"underthe
Rehabilitation ofOffenders Act1974).
Please Select
Please Select
PanelMemberships
1. Pleaselistdetailsof anysolicitorswithrelevantpanelmemberships:
Name / DateofJoining / AVMA / APIL / MASS / LawSocietyPIPanel / LawSocietyClinicalNegligence
Panel
Accreditations
1. Pleaseselectanyaccreditationsthatyourfirmhas:
Yes/No / DateofAccreditationInvestorsin People / Please Select
ISO / Please Select
LEXEL / Please Select
2. Pleaseprovidedetailsof thecasemanagementsoftwareusedwithinyourfirm:
ConditionalFeeBusiness
1. Approximatelyhowmanyconditionalfeecasesdidyourfirm conductlastyear?
MotorInjuryEL
PL
OL
ClinicalNegligence
IndustrialDisease
PersonalContract
CommercialContract
Other(pleasestate)
2. Doyoucurrentlyofferaconditionalfeeinsurancescheme?Please Select
Ifyes pleaseprovidedetails:
ProviderName / PercentageofTotalCFAcases / DisbursementFunding?Please Select
Please Select
Please Select
Please Select
Please Select
Total:
3. Ifweofferyouaschemefacility,will youbeusinganotherATEprovideralongsidethe ARAGscheme?Ifyes, pleaseprovidea)detailsof theprovider/sb)thenumberof casestheywillreceive:
Method / Yes/No / PercentageofTotalCFAcasesLocalReputation / Please Select
ClaimsManagementCompanyReferrals / Please Select
NewspaperAdvertising-Local / Please Select
NewspaperAdvertising-National / Please Select
RadioAdvertising-Local / Please Select
RadioAdvertising-National / Please Select
TVAdvertising-Local / Please Select
TVAdvertising-National / Please Select
Online-Website / Please Select
Total:
4. Pleasegivedetailsofyourcurrentconditionalfeefundingarrangements:
Method / Yes/No / PercentageofTotalCFAcasesPracticeFunding / Please Select
WorkinProgressFunding / Please Select
CCACaseFunding / Please Select
Other(pleasestate) / Please Select
Total:
Supervision/RiskAssessment
1. Pleaseprovidethenameof thepartnerwithoverallresponsibilityforthefollowingareas:
Area / NameMotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDisease
PersonalContract
CommercialContract
2. Doyouhaveawrittenrisk assessmentpolicy?Please Select
Ifyes pleaseprovidedetails:
3. Pleaseprovidethenamesof feeearnersauthorisedto acceptCFAcases:
Area / NameMotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDisease
PersonalContract
CommercialContract
4. Howoftendoyoureviewafileforrisk assessmentpurposes?Please Select
5. Doyouprovideregulatorytrainingforyourstaffinthefollowingareas?
Yes/NoFCA / Please Select
DataProtection / Please Select
MoneyLaundering / Please Select
FinanceComplaints / Please Select
ConditionalFeeCaseHistory
1. PleaselistConditionalFeeCaseHistory:
Year Case Opened / CaseType / CFACase Experience
CaseNumbers / Costs IncurredonLost Cases
Won / Lost / Discontinued / Open / Own
Disbursements / OtherSide’s
Costs
2008 / MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDiseaseVWF
IndustrialDiseaseNIHL
IndustrialDiseaseMeso
PersonalContract
CommercialContract
Other
Total:
2009 / MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDiseaseVWF
IndustrialDiseaseNIHL
IndustrialDiseaseMeso
PersonalContract
CommercialContract
Other
Total:
2010 / MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDiseaseVWF
IndustrialDiseaseNIHL
IndustrialDiseaseMeso
PersonalContract
CommercialContract
Other
Total:
2011 / MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDiseaseVWF
IndustrialDiseaseNIHL
IndustrialDiseaseMeso
PersonalContract
CommercialContract
Other
Total:
2012 / MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDiseaseVWF
IndustrialDiseaseNIHL
IndustrialDiseaseMeso
PersonalContract
CommercialContract
Other
Total:
DATAPROTECTIONNOTIFICATION
Inaccordancewiththeprovisionsof theDataProtectionAct1998,anypersonalor sensitive datasuppliedto ARAGplc willbeheldin asecuredatabaseandusedsolelyforthepurposeof thisapplication.Thisinformationmaybeforwardedto anappropriatethirdpartybutsolelyfor thepurposesof processingthisapplication.
DECLARATIONS
I/Wedeclarethatthe informationgiveninthisapplicationis trueandcompleteandI/weagree thatthisshallbe thebasisof anyagencyagreement.I/Weunderstandthatifanyof the informationis foundtobeuntrue,thattheagencycanbeterminatedat thesolediscretionof ARAGplc.
I/WedeclarethatARAGplc willbeadvisedpromptly,in writing,:
a.of anychangeof address,
b.of anychangesof Directors,Controllers,PrincipalsorPartners,
c.intheeventof theAgentbecomingbankrupt,insolvent,goingintoliquidation,enteringinto anagreementwithanycreditorsorreceiversbeingappointed,
d.of anychangesof thecapitalstructureof thebusiness,
e.ifanyPartner,DirectororControllerof theAgentisorbecomessubjecttodisciplinary proceedingsinstitutedbyaprofessionalorsimilarbody,
f.of anyconvictionsforCriminaloffences(otherthanmotoringoffences)of anyDirector, Controller,PrincipalorPartneroccurringafterthedateof thisApplication,
g.ifanyagencyappointmentwithanotherInsureris terminated,
h.ifanyregistrationundertheFCAormembershipof aprofessionalbodyis terminated. I/Wealsodeclaretomaintaininforceprofessionalindemnitycover.
I/WeunderstandthatARAGPLCmaytakeupreferencesinconnectionwiththeapplication.
I/Weunderstandthatcompletionof thisdocumentdoesnotconstitutethegrantingof anAgency withARAGPLC.I/Wefurtherunderstandthegrantingof anAgencyis subjecttobothparties signinganddatingtheCompany'sTermsof BusinessAgreementwhichwillbereceivedfrom the Companyuponitacceptingthisapplication.
AuthorisedSignatory: Date:
AuthorisedSignatory: (BLOCKCAPITALS)
Position:
ConsentForm
Thisdocumentmustbecompletedandsignedbytheapplicantinaccordancewiththebank mandatecurrentlyinforce.
I/We
Authorise:
Branch:
Address:
PostCode:
ClientA/Cno.:
toprovideARAGPLC,9WhiteladiesRoad,Bristol,BS81NNwithastatusenquiry/financial referenceonme/us.
Signed:Position:
Date:
Pleasesavethisformandsendviaemailorpost