Starting date of coverage is March 31, 2014

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1 Ontario Council of Hospital Unions / CUPE has partnered with LMS PROLINK to provide Professional Liability Protection (PLP) exclusively for Registered Nurses who are members of CUPE. For over 30 years LMS PROLINK has been a 100% Canadian owned independent insurance brokerage serving members of unions and associations. We are pleased to announce that OCHU and LMS PROLINK have found a solution that is not only cost-effective, but provides comprehensive coverage required by RN s in Ontario. HIGHLIGHTS INCLUDE:! Members can obtain $1,000,000 in Professional Liability Protection for a total annual cost of $205 + tax. Higher Limits are also available up to $5,000,0000 ($285 + tax). All with no deductible!! Complete online solutions Apply and pay in less than 5 minutes!! PLP exceeds the minimum requirements of Bill 179 and the College of Nurses of Ontario.! Coverage extended to RN services rendered outside of your employment agreement with a hospital or Long- Term Care Facility! Members do not have to pay fees to a separate Nursing Association in order to access competitive group insurance rates! LMS PROLINK is excited to work with OCHU and CUPE in protecting the careers of RN s. Starting date of coverage is March 31, 2014 For further information on LMS PROLINK please visit or contact: Jonathan Bracamonte Account Executive P: TF: E: OCHU@LMS.ca LMS PROLINK Ltd. 480 University Ave. Suite 800 Toronto ON. M5G 1V2

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3 OCHU/CUPE Professional Liability Insurance Instructions for RN s To apply for liability insurance or to view plan pricing and coverage please follow these simple instructions: 1. Go to 2. Click on the APPLY ONLINE 3. If logging in for the very first time use the following generic credentials: a. User Name: ochurn b. Password: ochu12rn 4. This will get you into the online application. You will be asked for your CNO Registration Number and CUPE local number and complete the application. You will also be prompted to set up a unique account using your own as the user name and your own password. This will be the credentials you use from now on to log back into the system to print your evidence of insurance. 5. If you pay with Visa / MasterCard (and there are no concerns with your application) you will be able to bind coverage immediately and we will you your evidence of insurance. A credit card receipt will also be automatically ed to you. 6. If you choose to mail the application please make cheque payable to LMS PROLINK Ltd. and mail to: LMS PROLINK, 480 University Ave, Suite 800, Toronto, ON M5G 1V2 If these instructions are unclear, or if you require more information please contact LMS PROLINK directly at OCHURN@LMS.ca or at by calling our office toll free at during regular business hours (M-F, 8am to 5pm EST).

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5 APPLICATION FOR CUPE NURSES UNION Professional Liability Insurance 1. Answer all questions. If the answer requires detail, please attach a separate sheet. 2. Application must be signed and dated by the applicant 3. PLEASE READ CAREFULLY THE STATEMENT AT THE END OF THIS APPLICATION. 1. APPLICANT INFORMATION Legal Name of Applicant: Address: Phone: College Certificate of Registration Numbers: CUPE Local Number: Profession: Registered Nurse Registered Practical Nurse 2. APPLICANT SERVICES Please give the approximate percentages of time spent in the following work locations: % NP-led Clinic % Emergency Dept % Patient s Residence % Family Health Team % Operating Room %Physician s Office % Community Health Centre % Hospital Ward % Retirement Homes % Others, please % Air Ambulance % Obstetrics* specify: *Please provide a brief summary of services provided for Obstetrical Care. Are you working part time as an Individual Practitioner or in a Private Practice? Yes No 3 INSURANCE COVERAGE REQUIRED Choose Option * Professional Liability Insurance Limit Per Claim (CLAIMS MADE) Annual Premium Premium Tax (8%) Administration Fee $1,000,000 - $0 Deductible $ $16.00 $5.00 $ $2,000,000 - $0 Deductible $ $18.00 $5.00 $ $5,000,000 - $0 Deductible $ $22.40 $5.00 $ *Extensions: Abuse and Molestations: $25,000 each claim / $100,000 aggregate limit Total Insurance Cost (includes Administration Fee) 4. APPLICANT HISTORY Have you: (i) Ever been the subject of disciplinary or investigatory proceedings or reprimand by an administrative or governmental agency, hospital or professional association?... Yes No (ii) Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses?... Yes No (iii) Ever been treated for alcoholism or drug addiction?... Yes No (iv) Ever had any insurance company or Lloyd s cancel, decline, refuse to renew or accept only on special terms their malpractice insurance?... Yes No 1 APPLICATION FOR CUPE NURSES UNION v2

6 5. CLAIMS Has any claim or suit been brought against you?... Yes No If yes, please complete a supplemental claim information form for each claim or suit. Are you aware of any circumstances which may result in a malpractice claim or suit being made or brought against you?... Yes No If yes, please provide claims on a separate sheet. WARRANTY STATEMENT WARRANTY: I warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by the issuance of a policy. I authorize the release of claim information from any prior Insurer to LMS Prolink Ltd... SIGNATURE Name of Applicant Signature of Applicant Date SIGNING this application does not bind the Applicant or the Insurer to complete this insurance, but a copy of this application forms a part of the insurance policy if issued. 2 APPLICATION FOR CUPE NURSES UNION v2