Fillable Professional Indemnity Insurance for Barristers 202122 Application for (Australian National University)

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Professional Indemnity Insurance for Barristers 202122 Application for (Australian National University)

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{00245082:1} Page 1 of 4
Professional Indemnity Insurance for Barristers
2021–22 Application for Insurance
LPLC’s policy provides cover of $2m per loss (inclusive of claimant’s costs and defence costs)
for claims made against an insured barrister:
(a) during the period of insurance; or
(b) during or after the period of insurance and arising from a reported circumstance.
The policy provides for unlimited reinstatements.
1. Applicant details
Full Name of barrister
Junior ☐ OR Silk ☐
Chambers Address
Phone number (best
contact)
Email address
Name of Clerk
To complete your application for insurance:
1. Complete applicant details
2.
Provide actual or estimated gross fee income (GFI) details, as applicable
3. Complete concessional premiums details
4. Sign and date declaration
5.
Calculate your premium with reference to the table on page 4
6. Make premium payment and email the completed form along with the banking
receipt for payment to: renewals@lplc.com.au.
{00245082:1} Page 2 of 4
2. Financial details
Please provide the Gross Fee Income (GFI) information requested below.
GFI refers to fees received, inclusive of clerking commission but exclusive of GST.
Financial year
Gross Fee Income
Actual 2019–2020
$
Estimated 2021–2022
(only for barristers who signed
the Bar Roll after 1 May 2020)
$
Please note that LPLC may ask for verification of your GFI declaration.
3. Concessional premiums
A concessional premium is available if you answer ‘YES’ to one of the following:
Was 90% or more of your 2019/20 GFI [or for barristers who first signed the Bar Roll after 1 May
2020 the estimated 2021/22 GFI] derived from the practice of criminal law (this includes matters
intimately connected with the defence or prosecution of an actual or anticipated criminal law
matter such as crimes compensation, confiscation of the proceeds of crime, apprehended
violence/intervention orders, child protection, and coronial or other investigative processes)?
Yes ☐ No ☐ (tick appropriate)
Was 90% or more of your 2019/20 GFI [or for barristers who first signed the Bar Roll after 1 May
2020 the estimated 2021/22 GFI] derived from the conduct of matters in the Children’s Court of
Victoria?
Yes ☐ No ☐ (tick appropriate)
Do you propose to practise exclusively as a mediator for the year commencing 1July 2021?
‘Mediator’ for this purpose does NOT mean acting as an arbitrator or a determining expert.
Yes ☐ No ☐ (tick appropriate)
Do you propose to practise exclusively as an arbitrator with express statutory immunity for the
year commencing 1July 2021?
Yes ☐ No ☐ (tick appropriate)
Victorian Bar Professional Standards Scheme (PSS) membership
LPLC seeks the following information for claims management and reporting purposes only.
Will you be a member of the Victorian Bar Professional Standards Scheme (PSS)?
Yes ☐ No ☐ (tick appropriate)
{00245082:1} Page 3 of 4
Privacy Collection Notice
LPLC collects the personal information on this form for the purposes of processing your application for
cover, providing insurance and risk management services and performing our statutory functions. If you
do not provide all or some of this information, we may not be able to process your application for cover
or provide you with our services. In the course of performing our insurance and risk management business
activities we may disclose all or some of the personal information on this form to third parties such as
external claims panel lawyers and experts, consulting actuaries, auditors, reinsurance brokers, reinsurers,
and other service providers to LPLC.
The information on this application may also be provided to the Victorian Bar Inc.'s senior administrative
officer from time to time and any staff member or consultant who undertakes like obligations of
confidentiality. Subject to their keeping confidential the identity of the Insured and that of other parties
involved in any claim or notification, the information supplied may be used by the Victorian Bar Inc. only
for the purposes of:
a. Providing professional indemnity insurance for barristers and determining terms and conditions of
cover and premiums.
b. Providing assistance in relation to a claim or notification as may be appropriate.
c. Obtaining and maintaining reinsurance for Victorian barristers.
d. Developing risk management strategies.
e. Maintaining a comprehensive and up-to-date claims history database.
f. Developing risk management strategies.
g. Establishing and maintaining a Professional Standards Scheme for the Victorian Bar.
h. Setting subscriptions for membership of the Victorian Bar.
Individuals can contact LPLC to request access to any personal information we hold about them by
emailing lplc@lplc.com.au.
For further information on how LPLC handles personal information, please see LPLC’s Privacy Policy which
can be found at https://lplc.com.au/privacy.
4. Declaration
I hereby apply to the Legal Practitioners Liability Committee (LPLC) for professional indemnity
insurance for the 12 months commencing 1 July 2021.
I am or will be admitted to practise as an Australian Legal Practitioner for the period of 12
months from 1 July 2021. I will be carrying on practice in Victoria as a barrister only, pursuant to
a practising certificate issued by the Victorian Legal Services Board.
All information contained in this Declaration is accurate and complete. I understand LPLC may
ask me to verify my GFI declaration on request.
I understand that a contract of insurance will not be entered into until the correct premium has
been received by the LPLC. This will be confirmed by way of the issue to me of an LPLC tax
invoice/receipt.
Signed: _________________________________________________________________________________________
Print Name: ___________________________________________________Date ____________________________
{00245082:1} Page 4 of 4
5. Premium calculation
Please calculate your premium according to the Table below. All premiums include GST and
stamp duty.
Actual 2019–20 GFI
(Please use estimated 2021–22
GFI if you signed the Roll after 1
May 2020)
Premium if less than 90% of GFI
is from criminal law practice or
Children’s Court matters
Premium if 90% or more of GFI is
from criminal law practice or
Children’s Court matters
Nil
$101.25
$50.63
$1 to $50,000
$206.99
$103.50
$50,001 to $75,000
$362.70
$181.35
$75,001 to $100,000
$464.41
$232.21
$100,001 to $125,000
$564.30
$282.15
$125,001 to $150,000
$662.39
$331.20
$150,001 to $200,000
$806.40
$403.21
$200,001 to $250,000
$991.80
$495.91
$250,001 to $300,000
$1,170.00
$585.00
$300,001 to $400,000
$1,424.69
$712.35
$400,001 to $500,000
$1,738.79
$869.39
$500,001 to $700,000
$2,157.30
$1,078.65
$700,001 to $900,000
$2,616.30
$1,308.16
$900,001 to $1,500,000
$3,194.10
$1,597.05
Over $1,500,000
$3,249.00
$1,642.50
The concessional premium for mediators and for arbitrators with express statutory immunity of
$117.34 inclusive of stamp duty and GST.
6. Payment
Payment is by direct deposit. Banking details for internet banking are as follows:
Legal Practitioners’ Liability Committee
BSB: 033 000
Account No: 20 2105
(use your name as the internet banking reference when making payment)
A copy of the receipt for my internet banking payment of $
____________
is enclosed with this
Application.
Legal Practitioners’ Liability Committee T: +61 3 9672 3800 F: +61 3 9670 5538
Level 31, 570 Bourke Street, MELBOURNE 3000 W: lplc.com.au ABN 45 838 419 536
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Completed 11 May 2021

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