Any member of the Law Society of Upper Canada exempt from payment of Professional Liability Insurance premiums who performs pro bono services on behalf of a non-profit organization(s), and who wishes to remain exempt from the premium, must apply for a continuation of the member's eligibility for exemption.

1. I am currently exempt from payment of Professional Liability insurance premiums. true     false

2. I perform or plan to perform pro bono professional services on behalf of a non-profit organization(s), and apply for a continuation of my eligibility for an exemption from payment of Professional Liability insurance premiums. true     false

3. The non-profit organization is:

Lawyer Name:     

LSUC No.:

Lawyer Address:

Telephone:

Lawyer Email Address:     

4. The activity of the Organization is (ie. its purpose, services provided)

5. The pro bono professional services I perform/will perform are:

6. The timeframe for the performance of these pro bono services is:

Please check this box to evidence your signature.