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Basis of CoverThe cover under the Scheme is to indemnify the Firm/legal practitioners against any civil liability incurred in the course of practice in Malaysia as governed by the Legal Profession Act 1976. For terms, conditions and exceptions pleaserefer to the Certificate of Insurance when issued by Insurers.

BEFORE COMPLETING THIS FORM PLEASE READ THESE IMPORTANT NOTICES 1. Your attention is drawn to Section 129(1) of the Financial Services Act 2013 (Malaysia). You are to

disclose in this Proposal Form, fully and faithfully, all the facts which you know or ought to know,otherwise the policy issued hereunder may be void.

2. Every question must be answered. You must fully and clearly give the information asked. If the space provided is not sufficient to record a complete answer, please record the answer on a separate sheet of paper, sign, date and attach it to the Proposal Form.

3. This Proposal Form must be completed and signed by the Proposer. If the Form is completed by any other person, you must ensure that you are aware of all information stated herein.

Question 1: Details of Firm mriF fo emaN )a(

dehsilbatse etaD )b(

(c) Address for correspondence

(d) Tel ________________________ Fax ______________________ E-mail __________________________

Question 2 (a): Details of Legal Practitioners

Please state whether Sole Proprietor (SP), Partner (P), Consultant (C) or Legal Assistant (LA)

No Full Name SP/P/C/LA Sijil Annual No.

PR PROPOSAL FORM 2015BA BAR COUNCIL MALAYSIA - PROFESSIONAL INDEMNITY SCHEME

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Question 2 (b): For each of the legal practitioners named in 2 (a) who established this Firm or joined this Firm from a previous firm AFTER 1.1.2010, please complete this question with the full name of the legal practitioner, name of the previous firm, dates the legal practitioner joined and left the previous firm and his position while at the previous firm

*Sole Proprietor (SP), Partner (P), Consultant (C) or Legal Assistant (LA)

No Full Name Previous Firm Date Joined Previous Firm

Date Left Previous Firm

Position at Previous Firm SP/P/C/LA*

Question 3: Non-Admitted Staff* [excluding those named in Question 2(a)] * Office Managers, Secretaries, Litigation & Conveyancing Clerks, Paralegals, Pupils, Office Boys, Typists, Messengers, etc. A part-time employee = ½ a full-time employee.

Number of Non-admitted Staff

Question 4: Gross Legal Fee Income

Last Financial Year Estimate for the Current Year

MR MR detibed seef lagel launna ssorG

MRMRdetibed seef l USA/Canadaaunna ssorG *

Total MR MR

* Note : USA/Canada fees relate to legal fees debited for work done in Malaysia or elsewhere for client(s) with an address in USA / Canada or owned/controlled by person(s) domiciled there.

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Question 5: Nature of Work: Please state estimated percentage of work based on the total gross annual legal fees debited in the last Financial Year to nearest whole number

(a) Company/Corporate/Commercial or Financial Work

(e.g. acquisitions, takeover, share issues, general company and

commercial work excluding conveyancing work, etc)………………………………. ______________________%

(b) Insolvency, Administration or Liquidations……………………………………….……______________________%

(c) Conveyancing of commercial real estate…………………………………………….._______________________%

(d) Conveyancing of residential real estate………………………………………….……______________________ %

(e) Taxation, Estate planning, Executorship and Trusteeship…………………………._______________________%

(f) Civil litigation……………………………………………………………………………. _______________________%

(g) Criminal litigation…………………………………………………………….………….._______________________%

(h) All other work (Please provide description)………………………………………. … _______________________%

Total 100 %

Question 6: Claims Experience

(a) Have any claims been made against the Firm or any legal practitioners named in Questions 2 (a) and 2 (b) including whilst at a previous firm since 1.1.2010? Please tick.

(b) Since 1.1.2010 has any letter of demand, notice of intended claim or any intimation or threat of a claim been received by the Firm?

YES NO

If “YES” please provide the following details for each claim or threatened claim (even if you have previously notified Insurers), attaching a separate page if necessary. (If there has been a claim which you have not notified, please write “Not notified” in the Date of Notification column.)

Date of Notification to Insurers (of writs, letters of demand or threat) Claimant / Potential Claimant

Settled (Yes/No)(If ‘Yes’ please provide the date

Insurers closed the file or copy of letter from Insurers/their agents)

Question 7: Circumstances which may reasonably be expected to give rise to a claim

Is any legal practitioner named in Questions 2 (a) and 2 (b), AFTER ENQUIRY, aware of any occurrence or circumstances which may reasonably be expected to give rise to a claim against him/her, any predecessor or any principal, consultant, or professional assistant including arising at that person’s previous firm in or of the Firm or its predecessor/s? Please tick as appropriate.

YES NO

If “YES” please provide full details of each occurrence or circumstances (attach a separate page if necessary). If the circumstance has been notified to Insurers previously, please state if matter is settled or not and/or Insurers’ confirmation on closure of notification.

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AUTHORITY TO INSURERS AND OTHER PARTIES

Authorisation: I/We hereby authorise the Insurers and/or adjusters and/or claims managers to disclose to the Bar Council of the Malaysian Bar, from time-to-time such information arising from any claim under the insurance cover issued to me/us to enable the Bar Council to have access to the complete claims information and/or data for the sole purpose of the management of the Mandatory Master Policy Scheme and its Risk Management objectives.

Provided always that it is expressly understood and agreed between the Bar Council and the Firm that such information as disclosed by the Insurers and/or adjusters and/or claims managers shall not render the Firm and/or the Legal Practitioners concerned to any disciplinary action by the Advocates & SolicitorsDiciplinary Board.

DECLARATION:I/We warrant that all the above statements are true and complete and, in relation to the answers to Questions 6 and 7, I/we have obtained written confirmation from each of the legal practitioners named in Questions 2 (a) and 2 (b). I/We agree that this completed Proposal Form shall be the basis of the contract between the Firm and the Insurers.

Signature of Partner/Sole Proprietor: _________________________________________

Name of signatory: _______________________________________________________

Date of signing: ___________________

Firm’s Stamp: ___________________________

______________________________________________________________________________________________________________________

Completion and signature of this Proposal Form does not bind the Proposer or the Insurers to complete a contract of insurance.

Question 8: Top-Up quotations

The Mandatory Limit of Indemnity starts at RM250,000 for a single-legal practitioner firm, increasing by RM50,000 for every additional legal practitioner up to a maximum of RM2,000,000. You may wish to obtain a quote to increase yourLimit of Indemnity. Please indicate the options you may need in the space below.

(i) RM (ii) RM (iii) RM

Jardine Lloyd Thompson Sdn Bhd (16674-K)Suite 10.2, 10 Floor Faber Imperial Court, 21A Jalan Sultan Ismail, 50250 Kuala Lumpur

Tel: (603) 2723 3388 / (603) 2723 3241 Fax: (603)2723 3301 / 03 / 27

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