February 22, 2018
In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbally?
--- Yes No
Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above?
--- Yes No
Has insurance coverage ever been declined or cancelled or the renewal thereof been refused?
--- Yes No
WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, IT IS AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.
Please indicate limits required
--- $100 $125 $140 $150
$1,000,000 per loss/$1,000,000 per policy period
$2,000,000 per loss/$2,000,000 per policy period
$2,000,000 per loss/$4,000,000 per policy period
$5,000,000 per loss/$5,000,000 per policy period
Applicant's consent to the transmission of the information contained in the application form
I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential.
Moreover, I authorize ENCON Group Inc., 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.
email@example.com. 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 Pharmacy Technician Society of Alberta.
I have read and agree to the terms listed above, and verify all information is correct.