Lawyers´ Insurance Association of Nova Scotia

• Part One: Member Information

• Lawyer: *
• Telephone: *
• Firm: *
• Fax: *
• Address: *
• Email: *
• CC the completed form:
  Yes   
• What firm were you with at the time the alleged error occurred? *
• Number of lawyers in firm at the time of alleged error? *
• Is your present firm aware of this matter? *
  Yes    No

• Part Two: Claimant Information

• Name of Potential claimant(s):
• Address:
• Telephone:
• Is the potential claimant an individual?
  Yes    No
• If “No”, have you, your family, or your firm ever had any beneficial interest, direct or indirect, or financial involvement with the claimant?
  Yes    No
• If “Yes”, please specify:
• Is/was there a solicitor/client relationship between you/the firm and the claimant?
  Yes    No
• If “No”, please explain:
• When were you retained to act for the client?
• What was the scope of your retainer?
• Is the client/claimant aware of the potential problem?
  Yes    No
• Are you continuing to represent the client/claimant?
  Yes    No
• If “No”, name and address of client/claimant’s new lawyer:
• Have your fees been paid?
  Yes    No
• If “No”, how much remains outstanding?
• Are you taking action to collect your fees?
  Yes    No
• If “Yes”, please explain:

• Part Three: Claim Information

  Certain dates are required for our claims tracking system. Please be specific in providing the following:

• When did the alleged error occur?
• When did you first become aware of a potential problem?
• When were you first put on notice, either oral or written, of a claim?
• How were you made aware of the potential problem?
• If you have received a statement of claim or other written notice, please attach a copy:
• Is there any proceeding (such as foreclosure, repossession, application or defence) requiring urgent attention?
  Yes    No
• If “Yes” by when?
• Estimate the amount of claim that may be presented against you:
• In your opinion, the likelihood of liability is:-- Select One --UnlikelyPossibleProbableDefinite
• Please identify other parties who may be involved in the dispute, e.g. Real Estate agent, bank, independent title searcher, appraiser, tortfeasors, insurers, etc:
• Please list all staff members directly involved in the matter out of which the alleged error arose, indicating status (partner, associate, articled clerk, legal assistant, secretary):

  Name	Status

• Part Four: Area of Law/Causes

• In which area of law were you retained? Please select one:-- Select One --AboriginalAdministrative/Boards/TribunalsAdmiraltyArbitrationBankruptcy/Insolvency/ReceivershipCivil LitigationCommercialCorporateCriminalEmploymentEntertainmentEnvironmentalEstate Planning and AdministrationImmigrationIntellectual PropertyMatrimonial & FamilyMediationReal EstateTaxOther
• Other area of law:
• Additional Information:
• What percentage of your practice was devoted to this area of law at the time of the alleged error?
• To assist in loss prevention initiatives, please select the underlying cause of the alleged error:-- Select One --Failure of an office system or procedure such as a diary system, clerical/mathematical errorFailure in file administration such as failure to follow up, overwork, procrastinationPoor communication with those inside your office, failure to supervise delegated workPoor communication with client(s) such as disputed retainer, instructions, consentPoor communication with others. Please describe below.Failure to know the law, limitation period, or properly apply the lawConflict, representing two or more parties, unrepresented party, financial interestOther. Please describe below
• Please explain in great detail why the above underlying cause of the alleged error occurred:

• Part Five: Statement of facts

• Please relate all relevant facts pertaining to this claim in chronological order.:

• Part Six: Excess Insurance

• Do you carry excess insurance coverage?
  Yes    No
• Has the other insurer been put on notice?
  Yes    No

• Part Seven: Verification - This form is prepared in contemplation of litigation

• Signature of Lawyer:
• Date:
• Name of Managing Partner:

Please enter in the word you see below: