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PANEL SOLICITOR APPLICATION FORM

Acasta European Insurance CompanyAddress: 5/5 Crutchett’s Ramp, Gibraltar, GX11 1AA.

Web: www.acastainsurance.gi | Phone: 00350 200 74684 | Email: [email protected]

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APPLICATION FORM

View more information online at: www.acastainsurance.gi

Any questions - Call us on: 0800 668 1350

1) PRACTICE GENERAL DETAILS

Name of Firm

Trading Name (if different)

Law Society Registration Number

Is the Practice: Partnership LLP Limited Company

Registered Office Address Co. Reg. No. (If applicable)

Postcode

Number of BranchesDate Practice Established

Date Incorporated (If LLP or LTD)

Does the Practice have an in-house IT Department? Yes No

Practice Website Address

Practice DX Address

2) CONTACT ADDRESS FOR THIS APPLICATION

Contact Name Position

Telephone Fax

Email

3) PROFESSIONAL INDEMNITY INSURANCE DETAILS Please provide a copy of the Insurance certificate

Insurer Policy Number

Limit of Liability Renewal Date

To the best of your knowledge and belief has any partner, director, shareholder or employee of the firm ever been:

(If Yes provide full details in Additional Comments or on separate sheet.)

a) convicted of any criminal offence (save minor motoringoffences) or is any offence pending? Yes No

b) subject to any disciplinary proceedings by the Law Societyor is any offence pending? Yes No

c) subject to a professional negligence claim or notificationthat such a claim is pending? Yes No

d) refused Professional Indemnity Insurance? Yes No

4) FINANCIAL CRIME POLICIES

Can you confirm that your company has and runs a compliant and up to date anti-money laundering, anti-bribery & corruption and financial sanction policy. Yes No


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APPLICATION FORM



5) INFORMATION DISTRIBUTION DIRECTIVE (IDD) & GENERAL DATA PROTECTION REGULATION (GDPR)

All disclosure docs issued are in accordance with the regulations imposed in the IDD. Yes No

The company has in place a compliant and up to date data protection policies and proceduresin place including all changes brought in new GDPR regulations. Yes No

Do all staff receive the relevant training and CPD as required under the provisions of theInsurance Distribution Directive? Yes No


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6) PRACTICE VOLUME OF CASES PER ANNUM PER TYPE

TYPE OF CASE ATE VOLUMES PER ANNUM FOR ACASTA INSURANCE

RTA

P/L

E/L

IND

DBA Protector

COMMERCIAL

OTHER

7) VERIFICATION OF IDENTITY, REFERENCE CHECKS AND DATA PROTECTION WAIVER

Please note that to comply with current regulatory requirements Acasta European Insurance are required to know their client. You may be required, to provide additional information from time to time, which will verify your practice and its partners etc.

8) DECLARATION AND AUTHORITY TO ACASTA EUROPEAN INSURANCE COMPANY LIMITED

We declare that the statements and particulars contained within this application form including any attachments and the appendices are true and correct and we have not suppressed or misstated any facts. We agree that all details within this application form and any subsequent agreements shall form the basis of any contract affected thereon. We undertake to inform Acasta European Insurance of any material alteration to these facts occurring before thecompletion of any agreement or at any time thereafter.

This application must be signed by a Partner or Director of the applicant firm in accordance with practice agreed mandates:

Position(Enter ‘Partner’ or ‘Director’ as applicable)

Name Signature Date

Please return this completed application to email: [email protected]


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