Enrollment Form ACSW

Social Workers Professional Liability and Commercial General Liability Insurance Policy Application

YOU MUST BE A MEMBER IN GOOD STANDING WITH THE ALBERTA COLLEGE OF SOCIAL WORKERS.

For more information, please send us a message at acsw@hdfinsurance.com.

ACSW - Professional Liability Insurance Online Application

Please check this box and fill out the required fields below to submit & pay for a ACSW - Professional Liability Insurance

A. General Information

Application Type

Effective Date

Name

Telephone

Registration No.

Fax

Address

B. Business Activities

For how many years have you been registered as a social worker in Alberta?

Are you involved in any business or profession other than social work?

If Yes, please explain

C. Past Activities

Have you ever been declined, non-renewed or cancelled by an insurer for Professional Liability Insurance?

Have you ever been investigated by, or suspended from practice by, any governing body of your profession?

Have you ever had a claim made against you arising out of the performance of social work services?

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

Does the Applicant, any of the Applicant's employees or any other person proposed for this insurance have knowledge or information of any fact, circumstance or situation which could reasonably give rise to a claim which would fall within the scope of the proposed insurance?

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.

If Yes, please provide details

E. Legal Information

— Privacy Disclosure and Consent

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.

— False information

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.

— Declarations and Signature

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

Please Select one of the following insurance program plans:

— Plan 1

Professional Liability (claims-made and reported)

$2,000,000 per claim$5,000,000 aggregate

Commercial General Liability (occurrence form)

$2,000,000 per claim$4,000,000 aggregate

Limited Abuse Liability Extension

$1,000,000 aggregate

Disciplinary Defence Costs Extension

$150,000 per claim$150,000 aggregate

Office Contents

Not covered

Annual Premium (includes $5 Administration Fee)

$125

— Plan 2

Professional Liability (claims-made and reported)

$2,000,000 per claim$5,000,000 aggregate

Commercial General Liability (occurrence form)

$2,000,000 per claim$4,000,000 aggregate

Limited Abuse Liability Extension

$1,000,000 aggregate

Disciplinary Defence Costs Extension

$150,000 per claim$150,000 aggregate

Office Contents

$25,000 Contents$500 Deductible

Annual Premium (includes $5 Administration Fee)

$240

— Plan 3

Professional Liability (claims-made and reported)

$2,000,000 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:

a. Increased Limits of Liability (Plans 1 & 2 Only)

You may elect to increase both your Professional Liability and General Liability Limits to $5,000,000 per claim.

To increase the Professional Liability to $5,000,000 per claim/$5,000,000 aggregate and the Commercial General Liability to $5,000,000 per claim/$5,000,000 aggregate, please indicate

If Yes, provide details

b. Retirement

If you formally retire, you may elect to purchase 7 Years of "Extended Reporting Period" coverage.

Date of Retirement

If formally retiring, the Applicant may purchase Discovery Coverage for the reporting of Professional Liability claims. This does not change the terms of the policy nor the scope of coverage provided. This coverage must be purchased prior to the date of retirement.

C. Social Work Students

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.

d. Vicarious Liability Extension

Option A — For members who incorporate and wish to extend coverage to their legal entity, and who do NOT have any employees or volunteers, and who do NOT rent, lease or own premises, the additional premium is $0.00.

Option B — For members who incorporate and who do have employees or volunteers, or who do rent, lease or own premises, the additional premium is $100.00, per Year.

If you are incorporated, you may wish to include your legal entity's name under your Insurance Plan.

Name of Incorporated Entity

Current Date

May 31, 2012

I have read and agree to the terms listed above, and verify all information is correct.