2020 Liability Insurance CoverageProrated as of January 1, 2020 CONTACT INFORMATIONName* First Last Address* Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Preferred Contact Email* TelephoneMEMBERSHIP INFORMATIONLicense Number*Important: Enter license Number as XX - XXXX (include the dash)Zone*See Zone Map to right. Professional Liability CoverageCoverage period: January 1 to July 1, 2020 [Enter '1' in the quantity box to select your coverage] Please allow 7 business days to receive an official PANL receipt. Mandatory Requirement Coverage$2 Million per occurrence $4 Million aggregate _______________________ $65.00 - Premium $9.75 - RST (Insurance Premium Tax) $25.00 - PANL Administration Fee $3.75 - HST Price: $ 103.50 CAD Quantity: Recommended Coverage$5 Million per occurrence $5 Million aggregate _______________________ $112.50 - Premium $16.88 - RST (Insurance Premium Tax $25.00 - PANL Administration Fee $3.75 - HST Price: $ 158.13 CAD Quantity: To help us match your online payment with your registration form please tell us the legal name on the credit card account used for payment.*Has a malpractice claim ever been made against you? Yes No Are you aware of any incidents or circumstances that could lead to a claim? Yes No Proof of Coverage & ConsentSection 14(e) of the Pharmacy Act, 2012 requires that "pharmacists' provide proof that he or she has obtained professional liability insurance coverage in a form and amount satisfactory to NLPB. The malpractice insurance policy purchased through PANL satisfies this requirement under the ACT. ConsentI consent to be contacted directly by email by Marsh Canada Limited and/or ENCON Group Inc., concerning the professional liability insurance coverage (primary and complementary) they make available to me through the Canadian Pharmacists Benefits Association and the Pharmacists' Association of Newfoundland and Labrador, and my eligibility and application for, renewal or, such insurance coverage. I understand that I may withdraw this consent at any time. Yes No Signature*I declare that the above statements are true and that I have not omitted, suppressed or misstated any material facts. Date*PAYMENTPlease note that this form is used for Liability insurance. If you have any questions, please contact PANL Office at 709-753-7881 prior to submitting. If there is an error in selecting the appropriate form and a refund is required, there will be a $25.00 administration fee applied automatically. Total $ 0.00 CAD Credit Card* DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Telephone:(709) 753-7881 Toll Free:(866) 753-7881 Email:email@panl.net
