Online Quote : ATE Insurance Providers

Online ATE Insurance Proposal Form
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 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.

1. YOUR CLIENTS DETAILS

Your Clients Name
(eg Mr Alan Sugar Lord)

Prefix
First
Last
Suffix
Date of Birth
(eg dd/mm/yyyy)
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Clients Contact Number
(Landline)
Clients Contact Number
(Mobile)
Has the client agreed to ATE cover?

2. LITIGATION FRIEND DETAILS - If applicable

Litigation Friend

Prefix
First
Last
Suffix
Relationship To Claimant

3. CASE DETAILS

Claim Type
Case Type
Date of Incident (Accident)
(eg dd/mm/yyyy)
Date of CFA if in place
(eg dd/mm/yyyy)
It is not necessary to have a CFA in place to obtain ATE Insurance
Opponents Name
Opponents Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Brief Circumstances of the Incident.

Alternatively, please provide (fax, post or email) as much documentation as you can that serves to illustrate the circumstances.

Send to ate@casefunds.co.uk
Injuries Suffered / Loss.

Alternatively, please provide (fax, post or email) as much documentation as you can that serves to demonstrate the injuries suffered and/or financial loss.

Send to ate@casefunds.co.uk
Please Provide Details of Evidence to Support The Claim.

Alternatively, please provide (fax, post or email) as much documentation as you can that further supports your clients claim/defence.

Send to ate@casefunds.co.uk
eg. Counsels Opinion, Medical Documents, Expert Witness, Photographs, Other
Has Liability Been Admitted?
Is Yes, date it was admitted
Is Opponent Insured?
If Yes, state Insurance Company Name.
Proceedings Issued?
If Yes, date of issue
Court of Issue & Claims Track
eg. Preston County Court - Multi Track
Damages Claimed or Estimated Value £
Estimate of Insured's Disbursments and Costs £
Estimate of Opponent's Disbursments and Costs £
Any Part 36 Offers or Payments?
If yes, please provide details
Prospects Of Success
(eg. 50 - 60%, 61 - 70%, 71 - 80%, 81 - 90%, 91 - 100%)
Likely Success Fee %
Is there existing legal expenses insurance?

If Yes, Provide details and explanation why ATE cover is required?
Additional Information here:

Alternatively, please provide (fax, post or email) as much documentation as you can that serves to demonstrate the strength of your clients claim/defence.

Send to ate@casefunds.co.uk

4. REPRESENTATIVE DETAILS

Law Firms Name
(Your Trading Style)
Law Firms Address
(Your Address)

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Law Firms Telephone
Fee Earner Telephone
(DDI or Mobile)
Your Reference
Introducer
if applicable
Introducer Reference
if applicable
Fee Earner's Name
(Submitted By)

First
Last
Fee Earner's Email *
(This email address will be used for all correspondence)

5. TERMS AND CONDITIONS

The information and statements are true to the best of my belief. I have not knowingly missed out any information or facts which are likely to affect a decision to provide cover. I have never been convicted of any offence involving fraud or dishonesty *
 YES - I am prepared to pay the premium upfront 
 YES - I prefer a fully deferred premium till end of case 
 YES - Any of the two above, if available 
Infomation Requests *
 I Agree 
to respond promptly to any requests for updates requested by the ATE Insurance underwriter and to conduct the claim in accordance with the terms of business and procedures manual of that ATE Insurance underwriter.
Data Protection Act *
 I Agree to and understand that Case Funding Limited and the ATE Insurance underwriter/Company may use any of the information supplied for the purposes of underwriting and administering the policy. 
Any of the information supplied may also be used for dealing with any claims on a policy or any other similar activity.
Name of Proposed Insured *
By entering the name of the proposed insured the proposed insured will be bound by our terms and conditions.
Law Firm Name *
By entering your firms name you are binding the proposed insured and your firm to our terms and conditions.
Date *

DD 		/
MM 		/
YYYY
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