Legal Expense Insurance Application

We are proud to offer business owners comprehensive legal expense coverage

These policies offer you peace of mind that your business is protected against the potential costs involved in a legal dispute. You will be provided with best-in-class coverage that protects you from costs associated with appointing lawyers, court fees, expert’s fees, police reports, or medical reports. We will find the perfect policy to help you save time and money when dealing with employment disputes, legal defence costs, contract disputes and debt recovery, and more.

Basic Company Details

Are You an Existing Tripemco Client?

Company Name

Primary Address

Contact Name

Position

Email Address

Telephone Number

Website

Description of Business Activities

Last 12 Months Gross Revenue

Revenue From US Sales

Prior Legal Disputes

Legal dispute definitions available at bottom of this web page

Has the applicant had two or more of any of the below legal disputes in the last 3 years?

Employment Disputes:

Legal Defence:

Contract Disputes & Debt Recovery:

Statutory Licence Protection:

Property Protection:

Bodily Injury:

Tax Protection:

If yes to any of the above, please complete the questions below:

Dispute One:

Date of Incident or Dispute

Appointed a Lawyer?

Amount Paid in Legal Fees ($)

Type and Description of Issue

Dispute Two:

Date of Incident or Dispute

Appointed a Lawyer?

Amount Paid in Legal Fees ($)

Type and Description of Issue

Dispute Three:

Date of Incident or Dispute

Appointed a Lawyer?

Amount Paid in Legal Fees ($)

Type and Description of Issue

Have You Had More Than 3 Disputes in the Last 3 Years?

If Yes, Please Provide More Information on Each of the Additional Disputes:

Important Notice

By signing this form you agree that the information provided is both accurate and complete and that you have made all reasonable attempts to ensure this is the case by asking the appropriate people within your business. Tripemco Insurance Group will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the analysis of industry trends and to provide benchmarking data. For full details on our privacy policy please visit tripemco.com/privacy-policy

Description of Legal Disputes

Employment Disputes: Disputes commenced by employees, prospective employees, or ex-employees

Legal Defence: Providing legal assistance in a criminal investigation or defending against a criminal or occupational health and safety prosecution

Contract Disputes & Debt Recovery: Pursuing or defending a claim alleging breach of a contract for goods or services or pursuing accounts receivables
of over $1000.00

Statutory Licence Protection: Revocation, suspension, or non-renewal of an operating or business licence

Property Protection: Pursuing a claim for nuisance, trespass, or physical damage to business property

Bodily Injury: Pursuing a claim by an employee for a work-related injury

Tax Protection: Responding to a tax audit or appealing a Canada Revenue Agency (CRA) decision