Business Insurance | Specialty Programs | Canadian Association for Analytical and Environmental Laboratories Application

The Insurance Centre has developed a program designed to protect Canadian Environmental organizations with Errors & Omissions/Professional Liability coverage. For details, submit an application below, contact The Insurance Centre by phone (613.544.5313) or email us.

IMPORTANT: Arranging general insurance will require personal visits to our office to complete applications and provide signatures. In order to maintain a high level of service we are unable to consider requests for quotations from outside the Greater Kingston area.

• Applicant Name (Last, First)

• Email

• If different from above, state name under which business/practice is conducted

• Corporation Partnership Individual
• Date Firm established (DD/MM/YY)
• Number of years under present ownership

a) Address of main office

b) Address(es) of Branch Office(s)

a) Provide a full description of your operations

b) Are your operations controlled, owned or associated with any firm, corporation or company?
Yes No If yes provide full details ...

a) Provide the following information

Full name of all Partners/Principals	Qualifications	Date Qualified	Length of Time in Practice	Length of Time as Partner/Principal
•
•
•
•
•
•
•
•

b) Indicate the total number of employees

Professional		Sales Representative
Clerical		Other

c) Total number of partner, principals and employees who also act in the capacity of manager(s)

Explain fully the educational requirements of your profession ...

a) Does the Applicant belong to any related associations?
Yes No If yes, indicate such memberships ...

b) Are there any specific prerequisites for association eligibility?
Yes No If yes, provide details ...

Has the Applicant ever been investigated by or suspended from practice by any body governing the practice of his/her profession?
Yes No If yes, provide details of such investigation or suspension ...

Is any legislation currently in force governing the practice of the Applicant?
Yes No

a) Provide all details on all Errors and Omissions or Professional Liability Insurance carried in the past three years

Insurer	Period	Limit	Deductible	Premium
•
•
•

b) Indicate the type of Errors and Omissions or Professional Liability Insurance carried:
Claims Made Occurrence Basis

Has the Applicant had similar insurance declined, cancelled or refused during the past five years?
Yes No If yes, provide details ...

During the past five years, have the Applicant, Partners, Principals or Employees had one or more claims because of professional services, or are the Applicant, Partners, Principals or Employees aware of any facts, circumstances or allegations which may give rise to a claim?
Yes No If yes, provide details ...

a) Indicate your business'
Gross annual fees Income Commissions
For the past year: $ and anticipated for next year: $

b) What proportion of your fees, income or commissions is derived from clients outside Canada? Provide percentage for each country ...

a) Limits of Liability requested
Per occurrence $
Aggregate $

b) Deductible requested $

By submitting this application, the undersigned declares that all statements made in the Application and the information contained in the documents submitted with it are true. Submission of this application does not bind the Applicant to complete the insurance, but it is agreed that the Application shall be the basis of the contract, should a policy be issued.

A paper copy of this electronic form may have to be signed, as well.

Applicant

(Must be signed by a Principal, Partner, Controller, Executive Officer, Director or Manager.)

Disclaimer • All information provided on this site is for the sole use of The Insurance Centre, any unauthorized access to or use of this information may be deemed as a criminal offence which may result in prosecution.

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