Elite Insurance ATE Site

Online Proposal Form for Single Risk Assessed Policy

Please complete this form with as much information as possible and ensure all answers are accurate. If in doubt about the meanings of any of the questions please contact us. All field's marked with a * are required, non-completion of these fields will result in your form being rejected. All information provided in this proposal will form part of any contract and may affect how we determine any claim on the policy or it may make the policy invalid. A full copy of this proposal form and policy wording is available and can be downloaded from our web site www.elite-insurance.co.uk/document-library/

* Date of CFA or Retainer

* (select box to select date from calendar)

Appointed Solicitors Details
* Firm Name
* Fee Earner
* Reference
* Address
Address 2
*Town/City
*County
* Postcode
DX Number
DX Location
* Telephone Number
Fax Number
* Email Address
Counsels Name
Counsels Chambers

Insured’s Details
Insured's Title
* Insured's/Contact Forename
* Insured's/Contact Surname
* Address
Address 2
*Town/City
*County
* Postcode
Email Address
Telephone Number
Company Name
Date of Birth

* (select box to select date from calendar)
National Insurance Number
* Is there a Litigation Friend? Yes No

Opponents Details
Opponents Title
* Opponents name
Address
Address 2
Town/City
County
Postcode
Telephone Number
Fax Number

Referrers/Brokers Details
Referrers/Brokers Name
Reference

Claim Details
* Claim Type
If Other, please enter here
* Incident Date
* (select box to select date from calendar)
Brief Circumstances of the Incident/Case
(Maximum characters: 250)
You have 250 characters left.
Injuries Suffered

Evidence
Complexity of the Legal Issues
Complexity of the Evidential Issues
Type of Evidence Relied Upon
Expert Evidence Required
If Other, please enter here

Liability
* Has liability been admitted?
Date Liability Admitted

* (select box to select date from calendar)
Is Opponent Insured
If Other, please enter here

Proceedings
Proceedings Issued
Date

* (select box to select date from calendar)
Court
Claims Track
Damages Claimed£

Value of Costs and Disbursements
* Are Costs and Damages
Recoverable from Opponent
* Provide an Estimate of the£

Insured's Full Disbursements and the Opponents Full Costs and Disbursements

Part 36 Offers / Payments
Have any Part 36 Offers /
Payment been made
If Yes Please Provide Details

Prospects of Success
* Prospects of Success
Likely Success Fee

Existing Legal Expenses Insurance
BTE LEI Cover & Trade Union Membership
* Does the Insured have BTE LEI
Cover or TU Membership?
If Yes Please Provide Reason
for ATE Cover
* Have you conducted BTE enquiries?

Premium Information
* Has the Client Agreed
to Pay the Premium

Additional Information
Additional Information
Elite Insurance Company Limited will not put a case on policy until it has fully accepted a proposal and the premium has been received in full (inclusive of IPT) or an undertaking for payment of the premium in full (inclusive of IPT) has been received.

Payment of the premium should be made to Elite Insurance Company Limited at Newton Chambers, Newton Business Park, Isaac Newton Way, Grantham,Lincolnshire NG31 9RT.

A full copy of this proposal form and policy wording is available and can be downloaded from our web site www.elite-insurance.co.uk/document-library/

Data Protection Act
I/We understand that Elite Insurance Company Limited may use any of the information I/we supply for the purposes of underwriting and administering a policy. Any of the information I/we supply may also be used for dealing with any claims on a policy or any other similar activity. I/We agree that any information I/we supply to Elite Insurance Company Limited may be sent to lawyers, medical agencies or other experts, any court, tribunal, loss adjusters or brokers or any other party associated with Elite Insurance Company Limited. I/We agree that I/we may be contacted from time to time by Elite Insurance Company Limited for updates on my claim. If you wish to see a copy of the information we hold on you then you can write to The Data Controller, Elite Insurance Company Limited, Newton Chambers, Newton Business Park, Isaac Newton Way, Grantham, Lincolnshire NG31 9RT.

Declaration
I/We declare that the above information and statements are true to the best of my/our belief and I/we have not missed out any information or facts which are likely to affect a decision to provide cover. I/We have never been convicted of any offence involving fraud or dishonesty or any offence of a similar nature.

* Do you want to defer the premium?
Yes
Provided that Elite Insurance Company Limited accepts this proposal and issues a policy and agrees to defer the payment of the premium in full (inclusive of IPT) I/We hereby undertake to make payment of the premium in full (inclusive of IPT) within 14 days of the claim having come to an end.
No
I/We will make payment of the premium in full (inclusive of IPT) prior to the inception of the policy provided that Elite Insurance Company Limited.

I/We agree that all information and statements in this proposal and any enclosures are and form part of the contract between me and Elite Insurance Company Limited.

I/We agree to respond promptly to any requests for updates requested by Elite Insurance Company Limited or their agents and to conduct the claim in accordance with the terms of business and procedures of Elite Insurance Company Limited.
* Name of Proposed Insured
By entering the name of the proposed insured the proposed insured will be bound by our terms and conditions.
Date

* (select box to select date from calendar)
* Name of Appointed Solicitor
By entering your firms name you are binding the proposed insured and your firm to our terms and conditions.
Date

* (select box to select date from calendar)
* Email address for confirmation