ACSW Application Form

Please note that the ACSW liability plan runs from May 1 and renews May 1 of the following year. Premiums will not be pro-rated for late attendees. Half-term applications are available for new applicants starting on Oct 31, through until May 1.


New Program Enhancements:

  1. Members requesting an ERP (Extended Reporting Period) for maternity leave before October 1st will receive a 50% return
  2. Members requesting an ERP for maternity leave after October 1st will not receive a premium refund, however they will then receive a 50% refund off their next 12 month premium
  3. Members must confirm in writing the date they are going on leave

Please note that we are unable to process these applications, so if this applies to you, then please contact us directly to complete the application.

Current Date
June 28, 2017

A. General Information

B. Business Activities

C. Past Activities

D. The applicant does hereby provide the following warranty to the insurer

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 under any policy issued by Trisura Guarantee Insurance Company.

E. Legal Information

The undersigned authorized representative acknowledges that any personal information provided in connection with the insurance applied for, including but not limited to the information contained in this Application, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of any investigation and inquiry in connection with this Application for insurance and, if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law.

Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any false information, or conceals information concerning any fact material thereto for the purpose of misleading any insurance company or other person, commits a fraudulent insurance act which is a crime.

The undersigned authorized representative of the Applicant:

(i) declares, after inquiry, that the statements and representations set forth in this Application, and all materials submitted to or requested by the Insurer in conjunction with this Application, are true;

(ii) acknowledges that these statements, representations, and materials are relied on by the Insurer and that they shall be deemed material to the acceptance of the risk assumed by the Insurer under the insurance applied for, should the insurance be effected; and

(iii) agrees that if the information supplied in connection with this Application changes between the date of this Application and the effective date of any insurance effected pursuant to this Application, the undersigned will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding indications, quotations and/or authorization or agreement to effect the insurance.

Signing of this Application does not obligate the Applicant or the Insurer to effect the insurance, but it is agreed that all materials submitted to or requested by the Insurer in conjunction with this Application are hereby incorporated by reference into this Application and made a part hereof. It is further agreed that this Application and all materials submitted to or requested by the Insurer in conjunction with this Application are the basis of and are deemed attached to and incorporated into any policy effected pursuant to this Application.

PLEASE NOTE: COVERAGE CANNOT BE EFFECTED UNTIL THIS APPLICATION HAS BEEN FULLY COMPLETED, DULY SIGNED AND DATED, AND THE PREMIUM HAS BEEN PAID IN FULL

F. Insurance Program Plans

  • Professional Liability (claims-made and reported)

    $3,000,000 per claim

    $5,000,000 aggregate

  • Commercial General Liability (occurrence form)

    $3,000,000 per claim

    $5,000,000 aggregate

  • Limited Abuse Liability Extension

    $1,000,000 aggregate

  • Disciplinary Defence Costs Extension

    $200,000 per claim

    $200,000 aggregate

  • Office Contents

    Not covered

  • Annual Premium (includes $5 Administration Fee)

    $125

  • Professional Liability (claims-made and reported)

    $3,000,000 per claim

    $5,000,000 aggregate

  • Commercial General Liability (occurrence form)

    $3,000,000 per claim

    $5,000,000 aggregate

  • Limited Abuse Liability Extension

    $1,000,000 aggregate

  • Disciplinary Defence Costs Extension

    $200,000 per claim

    $200,000 aggregate

  • Office Contents
    Learn More

    $25,000 Contents

    $500 Deductible

  • Annual Premium (includes $5 Administration Fee)

    $240

  • Professional Liability (claims-made and reported)

    $3,000,000 per claim

    $5,000,000 aggregate

  • Commercial General Liability (occurrence form)

    Not Covered

  • Limited Abuse Liability Extension

    $1,000,000 aggregate

  • Disciplinary Defence Costs Extension

    Not Covered

  • Office Contents

    Not Covered

  • Annual Premium (includes $5 Administration Fee)

    $95

G. Optional Coverages

Please contact HDF Insurance for details and premiums for any of the following options:

If you supervise students from a post-secondary program that is recognized by the Alberta College of Social Workers, you may elect to include them under your Insurance Plan for services they provide on your behalf while acting under your supervision.

Important

For new applications, the effective date of your certificate will be the date your application and premium are received by HDF Insurance.

Important

Premiums will not be prorated for late entries.

The Insurer shall pay on behalf of the Insured those amounts, in excess of the Deductible, the Insured is legally obligated to pay as Damages resulting from a Claim first made against the Insured during the Policy Period or Discovery Period, if exercised, and reported to the Insurer pursuant to the terms of this Policy for a Named Insured’s Wrongful Act in rendering, or failing to render, Professional Services for others, but only if such Wrongful Act first occurs on or after the Retroactive Date and prior to the expiration of the Policy Period.

Disclaimer: Please note that you must be a member of ACSW in order to apply for this insurance coverage.