ACMP Application Form

Please note that the ACMP liability insurance plan runs from July 1 and renews July 1 of the following year. Plans will be prorated on a quarterly basis only. Renewals are for July 1 and will be available starting on May 1 each year.

All premiums collected are fully earned by the insurer, no refunds available for early cancellation.


Application Type

Please select the type of application you are submitting below:

New Application

Choose this option for coverage starting immediately, or if you are a new applicant that does not have current coverage.
Renewal Application

Choose this option if you are an existing member that already has coverage and are renewing your application for coverage next term.

General Information

Current Date
September 22, 2018

Additional Information

Program Plans

Please select the program plan you wish to purchase. All plans include the following coverage:

  • Commercial General Liability — $1,000 Deductible
  • Professional liability — $2,500 Deductible
Plan Option 1 $575.00

  • Professional Liability — $1,000,000
  • Commercial General Liability — $1,000,000
Plan Option 2 $700.00

  • Professional Liability — $2,000,000
  • Commercial General Liability — $2,000,000
Plan Option 3 $835.00

  • Professional Liability — $3,000,000
  • Commercial General Liability — $3,000,000
Plan Option 4 $990.00

  • Professional Liability — $5,000,000
  • Commercial General Liability — $5,000,000

Property (Office) Contents Coverage

Please select the additional property contents coverage you wish to purchase. Learn More

No Coverage

Choose this option if you do not wish to add property to your purchase.

Option 1 $225.00

This option adds $10,000 of property (office) contents coverage.

Option 2 $275.00

This option adds $25,000 of property (office) contents coverage.

Applicant's consent to the transmission of the information contained in the application form

Disclosure

I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to Intact Insurance for the sole purpose of obtaining an insurance policy, and will be kept confidential.

Moreover, I authorize Intact Insurance, its insurers or service Providers to:

  • conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation;
  • in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, defending, negotiating or settling any claims, as required.

For more information on Intact Insurance's privacy policy, please contact privacy@intact.net

Declarations and Signature

By submitting this application for insurance, the applicant declares that, to the best of his/her knowledge and belief, the statements set forth herein are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The applicant further agrees that if any significant change in the condition of the Applicant is discovered between the date of this Application form and the effective date of the policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager.

Although submission of this Application form does not bind the Applicant to Purchase the insurance, the Applicant agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy.

It is also agreed that should a policy be issued, it is understood that eligibility for this program is contingent upon membership in good standing in the Alberta Chapter of The Association for Change Management Professionals.