Form Page: insurance

Insurance Application

Only available to current members in Canada

Full Name:

Address:

City:

Province:

Postal Code:

Home Phone:

Work Phone:

Mobile Phone:

Email::

Website:

Business Type:

Sole Propietorship

Partnership

Incorporated

Business Name:

Yes

Do you have any employees?

Receptionist, etc.

Number of non-professiona staff:

Number of professional staff:

Must have own Professional Malpractice coverage

Yes

Are you a student?

Please select the modalities that you would like to be covered.

Modality 1:

Reflexology

Modality 2:

Up to 5 modalities can be covered at no additional cost. Remember that you must be qualified for the covered modality.

Modality 3:

Modality 4:

Modality 5:

Modalities marked with " * " will have a 25% surcharge applied due to the higher risk by the modality.

Modality 6:

Modality 7:

For addditional modalities more than 5, there is a cost of $40 for each additional modality.

Modality 8:

Modality 9:

Download the list of modalities available for coverage (pdf).

Modality 10:

Yes

In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professioinal negligence in writing or verbally?

Yes

Has any insurer ever declined, cancelled or imposed special conditions for any coverage, for you or your entity in the past?

Yes

Is the Applicant or any of his/her employees aware of any facts, circumstances, or situations which may reasonably give rise to a claim, other than advised above?

If "YES" to any of questions 6-8, please provide full detials in the box below:

Yes

I understand that my OCR membership must be current at the time of this application and maintained throughout the year.

You must be a current member in good standing. Unfortunately, we cannot process your application.

Now

Specific Date

Start Date of Insurance Coverage:

10.

Please select Starting Date:

Important Notice:

1. Coverage cannot be bound unless this application form has been fully completed. The undersigned has the power to complete and execute this Application Form, on behalf of all persons proposed for this insurance and declares that, after inquiry, the statements set forth herein, together with all materials and information submitted or requested by the Insurer, is true.

2. Although the signing of this Application Form does not bind the undersigned nor the Insurer to effect insurance, it is agreed that this Application Form and its attachments shall be the basis of the contract should a policy be issued and shall be deemed to be attached to and form part of the policy. The Insurer is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. If the information in this Application Form materially changes prior to the Effective Date of this policy, the Insured will immediately notify the Insurer in writing and the Insurer may effect changes in, or withdraw, the quotation.

3. It is understood and agreed that if knowledge of any such facts, circumstances or situations exists, whether or not disclosed, any claim or action subsequently arising or developing therefrom shall be excluded from coverage.

4. Coverage is not bound until your payment is approved. Prices subject to change without notice.

Disclosure and Consent:

As part of my application for insurance I consent to the collection and use of personal information required for purposes of considering my application for errors and omissions insurance by the authorized insurance broker, Prolink Ltd and PROLINK Insurance Group Inc. The insurer and the broker are authorized to collect, use, and disclose personal information and provide such personal information to third parties, as required for the purpose of underwriting this application for insurance, as permitted by the relevant provincial and federal privacy laws or other applicable laws. The privacy policy can be viewed at the website www.prolink.insure

I understand that at any time I may ask to review the personal information pertaining to my application for insurance and the broker will be obligated to provide me with any information I am entitled to receive under the relevant provincial and federal privacy laws or other applicable laws.

I HEREBY DECLARE that the above statements and particulars are true to the best of my knowledge, that I have not suppressed or misstated any facts and I agree that this application shall form part of the insurance policy. I also acknowledge that I am obligated to report any changes that could affect the disclosures in this application that occur after the date of signature, but prior to the effective date of coverage.

I have read and understand the terms of this insurance application:

Please type your name, signifying that you accept the terms of this application: