Any lawyer member of the Law Society of Upper Canada (LSUC) 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, must apply for a continuation of the lawyer member's eligibility for exemption using this form.

In completing this form, I confirm that:

1. I am currently exempt from the payment of Professional Liability insurance premiums under the LSUC insurance program.

2. I will 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.

The pro bono professional services I will perform are:

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

Lawyer Name:
LSUC No.:

Please check this box to evidence your signature.