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Which type of Professional Therapy insurance are you seeking?(*)

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If you perform other in the business, list them here

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Website Address

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APPLICANT

Applicant Full Name(*)

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Company Name (or Individual)

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Phone Number(*)

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E-mail(*)

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Address 1:(*)

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Address 2:

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City(*)

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Province(*)

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Postal Code:

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Please provide the following details:

Is this a new company (company formed within the past 3 years)?(*)

Yes

No

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Is the applicant currently enrolled as a student?(*)

Yes

No

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Are any of the employees currently enrolled as students?(*)

Yes

No

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Does the applicant have locations or operations outside of Canada?

Yes

No

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BUSINESS OPERATION

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Last 12 months (expiring)(*)

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Next 12 months (estimates)(*)

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How many business activities/specializations and duties performed is the coverage being requested for?(*)

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Provide details on all applicants (please attach resumes). Please enter each applicant for each field in the exact same order.

Provide names of applicants, separated by new line

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Provide professional qualifications for applicants, separated by new line.

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Provide the date qualified, separated with new line.

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Provide the years in practice

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Provide the years as partner

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PREVIOUS INSURANCE

Has the Applicant ever had insurance refused or cancelled for this Company?

Yes

No

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Please explain the reasoning

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Medical Malpractice – Alternative Therapists

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APPLICANT

BUSINESS OPERATION

PREVIOUS INSURANCE