Application for Healthcare Practitioner
Group Insurance Program

Applicant Information:
  1. Name of Applicant :

Mailing Address:

City:Province:Postal Code:

Phone Res.: Phone Bus.:Fax:

Email: Website:

  1. Is your business: Sole Proprietorship  Partnership  Incorporated Company

If “Incorporated Company” please provide the incorporated name:

  1. Do you have any employees? YESNO

If “YES”, please complete “Appendix A” and we will provide you with a quote. Additional premium will apply.

Underwriting Information:
  1. Please disclose all professional services in which you are presently actively participating:(Check all that apply or specify below)

Acupressure / Aromatherapy / Body Talk /  Bowen Technique / Craniosacral
Doula / Hellerwork / Indian Head
Massage / Ion Foot Massage / Iridology
Lactation Consultant / Qi Gong / Reiki / Reflexology / Rejuvenating Face
Massage
Relaxation/Chair
Massage / Shiatsu / Swedish Massage / Thai Massage / Therapeutic Touch
Touch for Health /  Other (Please Specify):
  1. In the past, has the Applicant or any of his/her employees ever been the  YESNO

recipient of any allegations of professional negligence in writing or verbally?

  1. Has any insurer ever declined, cancelled or imposed special conditions  YES NO

for any coverage, for you or your entity in the past?

  1. Is the Applicant or any of his/her employees aware of any facts, circumstances,  YES NO

or situations which may reasonably give rise to a claim, other than advised above?

If “YES” to any of questions 5 – 7,please provide full details on a separate sheet and attach to your application.

Select your Coverage:
Coverage / Limits & Deductibles / Rates / Totals
Liability Coverage
Professional Liability / $2,000,000 Each Claim Limit
$6,000,000Aggregate Limit
$1,000Deductible / INCLUDED / $185.00*
Commercials General Liability / $2,000,000 Each Occurrence Limit
$6,000,000 Aggregate Limit
$2,000,000 Personal Injury Limit
$5,000 Medical Expense any one person
$25,000 Medical Expense any one claim
$500,000 Tenants Legal Liability
Tax Payable (* Ontario and Manitoba please include 8% tax): / $______
Total Amount Payable: / $______
Payment Information:

Please complete the following table:

Limits of Liability / Premium
Basic Package up to 5 Modalities: / N/A / $185.00
Number of Additional Modalities (If more than 5): / _____ X $25.00 / $______
Total Premium:
Members Joining Between: / Percentage of Premium: / Total Premium Due:
November 1st, 2014 – January 31st, 2015: / 100%
February 1st, 2015 – April 30th, 2015: / 75%
May 1st, 2015 – July31st, 2015: / 50%
August 1st, 2015 – October 31st, 2016: / 125%
Sub-Total: / $______
PST (8% for Ontario Residents) or
RST (8% for Manitoba Residents): / $______
Total Amount Due: / $______
ALL PREMIUMS ARE SUBJECT TO APPLICABLE PROVINCIAL SALES TAX AND ARE FULLY RETAINED.
Payment Options:
  1. Your payment will be processed on the date we received your form unless you specify a later date.
  2. Payment can be made by cheque, money order, VISA or MASTERCARD.
  3. Make your cheque/money order payable to LMS PROLINK Ltd and mail to:LMS PROLINK Ltd.
    480 University Avenue, Suite 800

Toronto, ON. M5G 1V2

  1. If you opt to use credit card, complete the attached Credit Card Authorization Form (Page 4).
  2. The amount charged to your card will be the “TOTAL AMOUNT PAYABLE”.

COVERAGE IS NOT BOUND UNTIL YOUR PAYMENT IS APPROVED

Important Notice to Applicant:

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.

Disclosure and Consent:

As part of my application for insurance I consent to the collection and use of personal information required for the purposes of considering my application for insurance by the insurer and the authorized insurance broker, LMS PROLINK Ltd., a member of The 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, and as required by the applicant’s association and/or governing body. I understand that at any time I may ask to review the personal information pertaining to my application for insurance and the insurer and 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 have reviewed the information in this Application, gathered information from all partners/directors/ officers/ employees/agents under this entity whether present or prior regarding their knowledge or awareness of any claims or situations which may give rise to any claims.

The Claim Information Forms, if any, that are attached to this Application include the details of:

  1. All facts, situations, and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against us (the Applicant);
  2. All facts, situations, and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against us (the applicant) in the future. All such claims, suits and incidents have been reported to our (Applicants) current or prior insurer(s). It is understood and agreed that all such claims, suits, arbitrations, fact situations and incidents will be excluded from coverage under any policy issued by the insurer.

It is understood and agreed that failure to provide true and complete response to any of the questions, statements or request for information in this Application or to provide any other information material to this Application may, at the sole option of the insurer, result in the voiding of the insurance policy issued in reliance on this Application and /or denial of coverage for specific claims asserted against us (the Applicant) or any other insured under the policy. The undersigned on behalf of the Applicant and all other insureds under this policy issued by the insurer, hereby waives any defense to an action by the insurer for voiding or revoking of the policy based upon misrepresentation of fact or failure to disclose material information in connection with this Application. The Applicant agrees to hold the insurer harmless from all loss as a result of any such misrepresentation or failure to disclose, including, without limitation, all costs and attorney fees incurred by the insurer in connection with said action for voiding or revoking the policy.

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 ofthe 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.

Applicant’s Signature:______Name (please print):______Date: ______

PLEASE COMPLETE AND RETURN THE APPLICATION AND PAYMENT BY ONE OF THE FOLLOWING METHODS:

 Via EMAIL please send to:

 Via FAX please send to: 416 595 1649 attn.HPGPPROGRAM MANAGER

 Via MAIL please send to: LMS PROLINK Ltd. 480 University Ave. Suite 800 Toronto, ON. M5G 1V2

Credit Card Payment Authorization Form:

Date of Transaction:

Customer Code / Customer Number:

(TO BE COMPLETED BY LMS PROLINK)

Entity Name:

Name of Person Authorizing Payment:

Name on Card:

Type of Card: VISA MASTERCARD

Credit Card Number:

Credit Card Expiry Date:

Total Amount to Be Charged:

Request from CSR/TSR:

(TO BE COMPLETED BY LMS PROLINK)

Healthcare PractitionerGroup Insurance Program App(10 23 14)Page 1 of 4

LMS PROLINK Ltd. | 480 University Ave. Suite 800 Toronto ON. M5G 1V2 | TF: 800 663 6828 | F: 416 595 1649 | E: