2022-2023 Professional Liability Insurance Coverage 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* Professional Liability CoverageCoverage period: July 1, 2022 to July 1, 2023 [Select your coverage Mandatory or Recommended] Mandatory Requirement Coverage $2 Million per claim $4 Million aggregate _______________________ $130.00 - Premium $19.50 - RST (Insurance Premium Tax) $25.00 - Brokerage fee to CPBA waived as per decision of CPBA $25.00 - PANL Administration Fee $3.75 - HST Recommended Coverage $5 Million per claim $5 Million aggregate _______________________ $225.00 - Premium $33.75 - RST (Insurance Premium Tax $25.00 - brokerage fee to CPBA waived as per decision of CPBA $25.00 - PANL Administration Fee $3.75 - HST Select Coverage Option* Mandatory Recommended 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 any application for Professional Liability insurance ever been denied or cancelled?* Yes No Have you ever sustained a Professional Liability loss or has such a claim been made against you in the last five years? Only answer Yes if you have not already reported this to BMS/Crawford.* Yes No Have you any knowledge of any negligent act, error or omission or breach of duty which might give rise to a claim against you? Only answer Yes if you have not already reported this to BMS/Crawford* Yes No ConfirmationIf you have answered YES to one of more insurance questions above, please contact CPBA’s insurance program broker, BMS Canada Risk Services Ltd. at email@example.com. BMS will review your insurance application and they will assist you in finalizing your coverage under the CPBA program. Declaration*I declare that during the last five years no insurer has cancelled, declined or refused to issue me any form of liability insurance and that this application discloses the hazards known to exist at the date of this application. I 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. Submitting this form does not bind the Applicant or company to complete the insurance but is agreed that this form shall be the basis of the contract should a policy be issued. The insurance premium is fully retained and not refundable. 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.Applicant's consent to the transmission of the information contained in the application.*I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to the insurer for the sole purpose of obtaining an insurance policy, and will be kept confidential. I consent I do not consent Consent*I consent to be contacted directly by e-mail by BMS Canada Risk Services Ltd. concerning the professional liability insurance coverage (primary and supplementary), they make available to me through the Canadian Pharmacists Benefit Association and the Pharmacists' Association of Newfoundland and Labrador, and my eligibility and application for, and renewal of, 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 $15.00 administration fee applied automatically. PANL Administration Fee* Price: Mandatory Requirement Coverage* Price: Recommended Coverage* Price: Mandatory Coverage RST (Insurance Premium Tax)* Price: Recommended Coverage RST (Insurance Premium Tax)* Price: HST $ 0.00 CAD Total $ 0.00 CAD Credit Card*Card Details Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.