SOCIAL WORKERS PROFESSIONAL LIABILITY AND COMMERCIAL GENERAL LIABILITY INSURANCE POLICY APPLICATION FOR THE OASW

Transcription

1 SOCIAL WORKERS PROFESSIONAL LIABILITY AND COMMERCIAL GENERAL LIABILITY INSURANCE POLICY APPLICATION FOR THE OASW Application SECTION 1: GENERAL INFORMATION YOU MUST BE A MEMBER IN GOOD STANDING WITH THE ONTARIO ASSOCIATION OF SOCIAL WORKERS TO APPLY FOR THIS PROGRAM. 1. Full Name of Applicant: Address: Address: Telephone: Fax: OASW Membership No.: Please note that this insurance program applies solely to social work services. How many years have you been practicing as a Social Worker in Ontario? SECTION 2: PAST ACTIVITIES 2. Have you ever been declined, non-renewed or cancelled YES NO by an insurer for Insurance? 3. Have you ever been subject to disciplinary action by, or suspended YES NO from practice by, any governing body of your profession? 4. Have you ever had a claim made against you arising out of the performance of social work services? YES NO If YES, please provide the following details on a separate sheet: (a) Date of Claim (b) Claimant s Name (c) Nature of Claim (d) Current Status of Claim 5. Does the Applicant, any of the Applicant s employees or any other person proposed for this YES NO 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. OAS W Insu rance Prog ram Applica tion ( ) Page 1 of 5

2 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. Name (please print): Applicant s Signature: Title: Date: OAS W Insu rance Prog ram Applica tion ( ) Page 2 of 5

3 SECTION 3: MANDATORY INSURANCE PLANS Select ONE of the following coverage plans: PLAN 1 PLAN 2 PLAN 3 (occurrence form): $3,000, per occurrence Not covered $ $ (occurrence form): $3,000, per occurrence $50, Contents $ Deductible $ $ Not Covered Not covered $98.00 $ SELECT PLAN 1 SELECT PLAN 2 SELECT PLAN 3 OAS W Insu rance Prog ram Applica tion ( ) Page 3 of 5

4 SECTION 4: OPTIONAL COVERAGES OPTIONAL LIMIT OF LIABILITY INCREASE: 1. Do you need to increase your per claim Limit for both Professional YES NO Liability and General Liability from $3,000,000 to $5,000,000? If YES than the additional premium is $ Please Note: This increase does NOT increase the amount of Liability coverage. OPTIONAL COVERAGE FOR STUDENTS UNDER SUPERVISION: 2. Do you supervise students from a post-secondary institution that has YES NO been accredited by the Canadian Association for Social Work Education? If YES, do you want to extend your coverage to include them while they are providing social work services on your behalf and while working under your direct supervision? If YES, indicate the number of students: Please Note: There is an additional premium charge of $25.00 per student. YES NO OPTIONAL COVERAGE FOR EQUINE-ASSISTED THERAPY: 3. Do you provide equine- assisted therapy as part of your social work services? YES NO If YES, your coverage will be extended for an additional premium of $ Please Note: There is NO coverage provided for anyone under the age of twelve (12) years old. OPTIONAL VICARIOUS LIABILITY EXTENSION: 4a. Is your social work business incorporated? YES NO If YES, provide the full legal name of your incorporated entity: 4b. If YES, do you have any social work professionals working YES NO through your incorporated entity, other than yourself? (if NO, go to Q. 4d.) 4c. If YES, do all other professionals working through your incorporated entity carry individual YES NO Errors & Omissions and coverage for their social work services? If YES, indicate the number of professionals (excluding yourself): Please Note: There is an additional premium charge of $50.00 per professional. Please Note: The Vicarious is available ONLY if all professionals carry individual Errors & Omissions and coverage. (If NO, vicarious liability is NOT available for this person) 4d. Do you employ any administrative or clerical staff, other than yourself? YES NO If YES, there is an additional premium of $ OAS W Insu rance Prog ram Applica tion ( ) Page 4 of 5

5 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. This policy provides Errors and Omissions insurance that applies on a claims-made basis. The following provides a general description of this coverage and is subject to the terms and provisions of the actual policy. A. The policy will not cover any losses from incidents which take place before the Retroactive Date, if any, or after the expiration of the policy period (subject to the Extended Reporting Period provision). B. The policy will provide coverage for losses from incidents which take place on or after the Retroactive Date, if any, but before the beginning of the policy period only if the insured did not know of the incident before the beginning of the policy period. C. The policy will not cover any loss for which a claim is first made after: 1. The expiration of the policy period or its earlier termination date, if any; or 2. The Extended Reporting Period if any and then only in accordance with the terms described in the policy. D. The policy will only cover claims which are first made: 1. During the policy period; or 2. During an Extended Reporting Period if any and then only in accordance with the terms and conditions described in the Extended Reporting Period Section of the policy. E. Please request a copy of the Policy and review the terms and conditions to obtain more information. F. The limits for Defence Costs are over and above the liability and will not reduce the limit of liability. Disclosure and Consent: As part of my application for insurance I consent to the collection and use of personal information required for the purposes of considering my application for insurance by the insurer and the authorized insurance broker for Ontario Applicants, LMS PROLINK Ltd., and/or the authorized insurance broker for applicants outside of Ontario, 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, and as required by the applicant s association and/or governing body. 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 of any claims or situations which may give rise to any claims The Claim Information Forms, if any, that are attached to this Application include the details of: A. All facts, 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); B. All facts, 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 insurer. 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 insurer, 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 the Applicant and all other insureds under this policy issued by the insurer, hereby waives any defense to an action by the insurer for voiding or revoking of the policy based upon misrepresentation of fact or failure to disclose material information in connection with this Application. The Applicant agrees to hold the insurer 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 insurer in connection with said action for voiding or revoking the policy. 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 THROUGH ONE OF THE FOLLOWING METHODS: Via EM AIL ple ase s en d to: Via FAX pl ea se send to: Via M AIL plea se s e nd to: att n. OASW PROG RAM MANAGER LMS P ROLINK Ltd U n iversity Ave. Suite 800 T o ron to, O N. M5G 1 V2 OAS W Insu rance Prog ram Applica tion ( ) Page 5 of 5