APPLICATION FOR THE HOLISTIC CHAMBER (HCC) · 2020. 6. 11. · Acupressure Aromatherapy Body Talk Bowen Technique Craniosacral Doula Hellerwork Indian Head Massage Ion Foot Massage

HCC Insurance P rogra m Appl i cat ion ( 09 08 16 ) Page 1 of 4

LMS PROLINK Ltd. | 480 Univers ity Ave. Suite 800 Toronto ON. M5G 1V2 | TF : 1 800 663 6828 | F: 416 595 1649 | E: [email protected]

APPLICATION FOR THE HOLISTIC CHAMBER OF COMMERCE (HCC) INSURANCE PROGRAM

SECTION 1: APPLICANT INFORMATION

1. Name of Applicant:

Mailing Address: City: Province: Postal Code: Phone Res.: Phone Bus.: Fax: Email: Website:

2. Is your business: Sole Proprietorship Partnership Incorporated Company

If “Incorporated Company” please provide the incorporated name:

3. 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.

SECTION 2: UNDERWRITING INFORMATION

4. 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 Personal Support Worker Other _____

5. 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?

6. Has any insurer ever declined, cancelled or imposed special conditions YES NO for any coverage, for you or your entity in the past?

7. 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.



SECTION 3: SELECT YOUR COVERAGE

Coverage Limits & Deductibles Rates Totals

Professional Liability: $2,000,000 Each Claim Limit

$6,000,000 Aggregate Limit

NIL Deductible

INCLUDED $ 185.00*

Commercial 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

$1,000 Deductible

Tax Payable:

Ontario residents please add 8% PST. Manitoba residents please add 8% RST. Newfoundland residents please add 15% HST. Quebec residents please add 9% QST. $____________

Total Amount Payable: $____________

SECTION 4: 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:

August 1st, 2016 – October 31st, 2016: Automatically includes the November 1, 2016 to October 31, 2017 renewal.

125%

November 1st, 2016 - January 31st 2017: 100%

February 1st, 2017 – April 30th, 2017 : 75%

May 1st, 2017- July 31st, 2017 50%

August1st, 2017 – October 31st, 2017 : 25%

Sub-Total: $_________________

Tax Payable:

Ontario residents please add 8% PST. Manitoba residents please add 8% RST. Newfoundland residents please add 15% HST. Quebec residents please add 9% QST.

$_________________

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

4. If you opt to use credit card, complete the attached Credit Card Authorization Form (Page 4).

5. 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

This is an application for insurance and the insurer is not obligated to accept the applicant for coverage. If a policy is issued, one signed copy of the application will be attached to the policy or certificate. Signature on the application form and submission of a premium payment does not bind the insurer to complete an insurance transaction with the applicant.

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 insurer and the authorized insurance broker, PROLINK Ltd and 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. 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 any error, omission or negligent act in the performance of professional services for others. The Claim Information Forms, if any, that are attached to this Application include the details of:

A. All fact situations and incidents which have occurred in the past and which may reasonably be expected to result in a claim, suit or arbitration against the us (the Applicant);

B. All fact 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 Company.

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 Company, 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 Applicant and all other insured under any this policy issued by the Company, hereby waives any defence to an action by the Company for recession of such policy based upon misrepresentation of fact or failure to disclose material information in connection with this Application. Applicant agrees to hold the Company 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 Company in connection with said action for rescission. 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.

Applicant’s Signature: _______________________ Name (please print): ___________________________ Date: __________________

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

V ia EM AIL p le as e s en d to : HCC@LM S.c a

V ia FAX p l ea se s e nd to : 416 595 16 49 att n. HCC P ROGR AM M ANAGER

V ia M AIL p l ea se s e nd to : LMS P ROLI NK Lt d . 48 0 U n ivers ity Ave. Su ite 800 T o ron to , O N. M5G 1 V2



CREDIT CARD PAYMENT AUTHORIZATION FORM

PLEASE NOTE: FULL PAYMENT WILL BE APPLIED TO THE CREDIT CARD INFORMATION SUBMITTED. ADDITIONAL FEES: Please note that a $35 fee wi l l be assessed for al l dec l ined credit card

due to funds not author ized/avai lable or inva l id card numbers .

Client Name or Entity Name:

Name on Card:

I hereby authorize LMS PROLINK Ltd. to charge the following credit card. YES NO

Name of Person Authorizing Payment:

Type of Card: VISA MASTERCARD

Credit Card Number:

Credit Card Expiry Date:

Total Amount to Be Charged: $

Date Credit Card is to Be Charged:

If no date is provided than charges will be processed immediately.

Email Address to Send Receipt:

If no email address is given than receipts will not be provided.

THE FOLLOWING WILL BE COMPLETED BY PROLINK STAFF: Customer Code: Name of Staff Member Processing this Form:

APPLICATION FOR THE HOLISTIC CHAMBER (HCC) · 2020. 6. 11. · Acupressure Aromatherapy Body Talk Bowen Technique Craniosacral Doula Hellerwork Indian Head Massage Ion Foot Massage

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