Afterthe Event SchemeApplication Form

FirmDetails
1. 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 / Dateof
Joining / AVMA / APIL / MASS / LawSocietyPIPanel / LawSocietyClinicalNegligence
Panel

Accreditations

1. Pleaseselectanyaccreditationsthatyourfirmhas:

Yes/No / DateofAccreditation
Investorsin People / Please Select
ISO / Please Select
LEXEL / Please Select

2. Pleaseprovidedetailsof thecasemanagementsoftwareusedwithinyourfirm:

ConditionalFeeBusiness

1. Approximatelyhowmanyconditionalfeecasesdidyourfirm conductlastyear?

MotorInjury
EL
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 / PercentageofTotalCFAcases
LocalReputation / 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 / PercentageofTotalCFAcases
PracticeFunding / Please Select
WorkinProgressFunding / Please Select
CCACaseFunding / Please Select
Other(pleasestate) / Please Select
Total:

Supervision/RiskAssessment

1. Pleaseprovidethenameof thepartnerwithoverallresponsibilityforthefollowingareas:

Area / Name
MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDisease
PersonalContract
CommercialContract

2. Doyouhaveawrittenrisk assessmentpolicy?Please Select

Ifyes pleaseprovidedetails:

3. Pleaseprovidethenamesof feeearnersauthorisedto acceptCFAcases:

Area / Name
MotorInjury
EL
PL
OL
ClinicalNegligence
IndustrialDisease
PersonalContract
CommercialContract

4. Howoftendoyoureviewafileforrisk assessmentpurposes?Please Select

5. Doyouprovideregulatorytrainingforyourstaffinthefollowingareas?

Yes/No
FCA / 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