SOEP Members Ontario Licensed Optometrists 2016

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1 General Application for Professional Liability Insurance SOEP Members Ontario Licensed Optometrists 2016 Intact Insurance Co. Broker: 3100 Steeles Ave. East, Suite 101, Markham ON L3R 8T3 All questions are to be answered as completely as possible. If a question is not applicable to your situation state N.A. If insufficient space, attach full details. 1. Name of Applicant:. Corporate Name if any:.. Postal Address: (Number) (Street) (City) (Prov.) (Postal Code) Business Telephone#... Cell#. Address:. Fax # Location of Operations: Applicant is an Individual Partnership Corporation Employee Other (give details):.. 3. Applicant is a Franchisee Franchisor 4. How long has applicant been engaged in his/her current occupation or business?. Has applicant operated under a different corporate name in the past? Yes No If yes, give details:.. 5. Describe the nature of the professional or business activities for which coverage is desired. (Attach any promotional material available): 6. Is Applicant engaged in any business or profession other than as described in Item 5? Yes No If yes, please explain: 7. a) Estimated gross receipts (all income, fees and commissions before deduction of expenses) for Applicant s profession or business activity for the coming policy year: $... b) Does the Applicant provide services or perform activities outside of Canada? Yes No If yes, give full details indicating the services provided as well as the location and gross annual receipts:... c) Do you write prescriptions? Yes No 8 List the educational and training requirements the Applicant has met as a prerequisite to operating in his/her profession or business. (Provide dates and name of institution, where possible.):.. 9. Where is Applicant and any employees licensed to practice his/her profession? Ontario 10. Since graduation, where has Applicant practiced his/her profession? 11. Does the Applicant specialize in any branch of his/her profession? Yes No If yes, please describe: Indicate the number of employees actively engaged in any phase of Applicant s profession or business: Professional:. Clerical:.. Other: (03/09) Rev 1.1 3/3/16 Page 1 of 5

2 13. Complete the following for any person performing professional activities we may request the resumes of each: Name Duties Professional Designation Years of Experience 14. Does Applicant, or his/her employees, have Professional Liability Insurance through a Professional Association? Yes No If yes, state: Professional Association Number Per Claim Limits Aggregate Primary or Excess 15. Is Applicant employed by any person, firm, association, or corporation? Yes No 16. a) Does Applicant operate a Quartz Lamp, X-Ray, Infra-Red Ray or Diathermy Machine or other similar equipment, or use Radium, Radioisotopes, or any radioactive material for treatment? Yes No If yes, give details:. b) Does Applicant use Radioisotopes, or any radioactive material for any services? Yes No If yes, give details: Is Applicant involved in any process of manufacture, construction design, testing or servicing of any equipment? Yes No If yes, give details:. 18 a) Does Applicant issue guarantees and/or warranties to customers? Yes No If yes, attach full details and copy of Applicant s form of guarantee or warranty. b) Does Applicant agree to hold any person or organization harmless against claims or suits arising out of Professional Liability? Yes No If yes, give full details: 19. Give particulars of all professional liability insurance held by the Applicant for past three (3) years. Type of Policy Claims Made Occurrence Policy Number Insurer Policy Limit Policy Period If the policy is subject to a Retroactive Date, give details: 7705 (03/09) Rev 1.1 3/3/16 Page 2 of 5

3 20. Give details of all Professional Liability claims brought against the Applicant during past five (5) years: Date of Accident Paid Amount Outstanding Details 21. Do these paid or outstanding amounts reflect any deductible provision(s) contained in existing or previous insurance policies? Yes No If yes, to what coverage(s) does/did the deductibles apply and what is/was the deductible amount? 22. Has the Applicant any knowledge of any circumstance which could result in claim or suit being brought against the Applicant? Yes No If yes, give details:. 23. Limits of Insurance desired: Minimum $2,000,000 Each Claim Errors & Omissions Malpractice Please select and check off the required limit. Write the applicable premium in the column. LIMIT OF INDEMNITY RATE PREMIUM $2,000,000 Per Claim, $6,000,000 Aggregate $685 $3,000,000 Per Claim, $6,000,000 Aggregate $850 $4,000,000 Per Claim, $6,000,000 Aggregate $900 $5,000,000 Per Claim, $6,000,000 Aggregate $950 $6,000,000 Per Claim, $6,000,000 Aggregate $1,000 Coverage Limits of Liability SELECTED LIMIT Each occurrence SELECTED LIMIT Aggregate each policy term Ontario add 8% TAX $ TOTAL INCLUDING TAX $ $ Deductible: NIL Legal Expense Insurance Limit including Disciplinary Actions $25,000 Aggregate Per Certificate Period Expert Witness $10,000 Per Claim Expert Witness $25,000 Aggregate Per Certificate Period Legal Consultation $10,000 Per Claim Legal Consultation $50,000 Aggregate Per Certificate Period Legal Expenses $25,000 Per Claim Legal Expense $25,000 Therapy and Counseling Expenses Endorsement (Claims Made) Deductible $1,000 On Legal Defense Costs Make Cheque payable to to be enclosed with completed application (03/09) Rev 1.1 3/3/16 Page 3 of 5

4 I/We declare that during the last five years no insurer has cancelled, declined or refused to issue me/us any form of liability insurance and that this application discloses the hazards known to exist at the date of this application. I/We declare that the statements made herein are in every respect true and correct and hereby apply for a contract of insurance to be based upon the truth of the said statements. I may have provided personal information in this document and by other means and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker s or insurance company s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf. Signed by: Date: Position: Broker: Optometrist 3100 Steeles Ave. E. #101 Markham ON L3R 8T3 Please return application with premium and tax to Telephone: Signing of this form does not bind the Applicant to complete the insurance (03/09) Rev 1.1 3/3/16 Page 4 of 5

5 Application completed in full. All questions must be answered. All pages # 1 to #4 must be returned. Relevant certificates and qualifications attached. Membership Documentation (e.g. Certificate of Membership). Copy of current policy (if you answered yes to question #19 Professional Liability Checklist Premium payment attached online Bank confirmation # Name of Bank: Internet Banking PAYMENT OPTIONS Each bank has designed a unique format for their web site. However, the necessary procedures are generally similar. 1. Under Bill Payment: Choose Add Payee/Bill. 2. Enter Holman. Choose All Categories and province Ontario and submit. 3. Under Bill company/payee - Select and enter your account number which is THE FIRST FOUR LETTERS OF YOUR LAST NAME FOLLOWED BY XX1 4. Select the account you wish to withdraw the funds from. (i.e. credit card, savings, chequing, line of credit). Indicate the amount of payment and submit. A confirmation and reference number will be displayed to acknowledge your payment. Telephone Banking 1. Request your bank set up a new Payee/Bill to do a Bill Payment. 4. Your banking institution will then take your payment over the telephone by your choice of payment method. Debit Card Payments 1. Contact your bank by telephone or visit in person. Request that they set up an option to allow you to make Bill Payments by Debit Card. 4. Once you have set up, you are able to proceed with payments via your branch ATMs with your debit card. 5. Choose banking option: Bill Payment and follow your bank instructions. In Person at the Bank 1. At your own bank, request they set up a new Payee/Bill to do a Bill Payment. 4. You can choose to pay via the different accounts you hold with that particular bank or by other financial institution credit cards. 5. When paying in person at different financial institutions, bring your invoice/statement and request to make a Bill Payment. 6. Advise the teller that the Payee is and follow the prompts from step #2. Note: Do not ask for a wire transfer or funds transfer, the banks charge you extra for this service and charge us extra for which we do not reimburse. These additional fees can range as high as $50 or more. By Mail Cheque or money order payable to: 3100 Steeles Ave. East Suite 101 Markham ON L3R 8T3 Credit Card 1. Go to 2. Click on Payment Options 3. Click on Master Card/ Visa icon and enter the required information (03/09) Rev 1.1 3/3/16 Page 5 of 5

HOLMAN INSURANCE BROKERS LTD.

HOLMAN INSURANCE BROKERS LTD. HOLMAN INSURANCE BROKERS LTD. 3100 Steeles Ave. East, Suite #101, Markham Ontario Canada L3R 8T3 Website: www.holmanins.com Telephone: 905-886-5630 Toll Free: 1-800-567-1279 Fax: 905-886-5622 E-mail: service@holmanins.com

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