2021-22 Liability Insurance Coverage | Upgrade from Student/Intern

CONTACT INFORMATION

Name*

First Last

Address*

Address City Province Postal Code

Preferred Contact Email*

Telephone

Membership Information

License #

Please include hyphen. Correct format XX - XXXX

Zone

Professional Liability Coverage

Coverage period: July 1, 2021 to July 1, 2022

Mandatory Requirement Coverage
$2 Million per occurrence
$4 Million aggregate
_______________________
$80.00 - Premium
$12 - Insurance Tax
$12.50 - CPBA Brokerage Fee WAIVED as per decision of CPBA
$12.50 PANL Administration Fee
HST $1.88
Total: $106.38

Recommended Requirement Coverage
$5 Million per occurrence
$5 Million aggregate
_______________________
$175.00 - Premium
$ 26.25 - Insurance Premium Tax
$ 12.50 - CPBA Brokerage Fee WAIVED as per decision of CPBA
$ 12.50 PANL Administration Fee
HST $1.88
Total: $215.63

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?*

Yes
No

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 & Consent

Section 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.*

Applicant's consent to the transmission of the information contained in the application.

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 Alberta Pharmacists' Association, 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*

PAYMENT

Please note that this form is used for upgrading your Liability insurance from Student/Intern to Regular Pharmacist. 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.

Select Preferred Coverage Option*

Mandatory Requirement Coverage
Recommended Coverage

PANL Administration Fee*

Price:

Mandatory Coverage RST (Insurance Premium Tax)*

Price:

Recommended Coverage RST (Insurance Premium Tax)*

Price:

HST

$ 0.00 CAD

Total Fee

$ 0.00 CAD

Credit Card

Card Details

Cardholder Name

Comments

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