MTAS Association Application

Association Application

Liability I Policy for active members of the Massage Therapy Association of Saskatchewan
This Individual Liability Policy is designed to cover you as an individual practitioner; it is not intended to cover employees, Sub-Contractors, Business Partners or Commercial Offices you may be renting over 200 SQFT.

ALL QUESTIONS MUST BE ANSWERED COMPLETELY. INDICATE “N/A” IF A QUESTION IS NOT APPLICABLE.
Please confirm you have read and understand the coverage limits and requirements for making changes.*

Yes, I have read and understand the coverage limits and requirements for making changes.
Applicant Information
Applicant Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Do any sports teams, professional or otherwise, employ you on a full-time, part-time or contract basis?*

YesNo
Please provide details on the sports team and /or type of athletes you work for and briefly describe your role on the medical staff including who you report to: *

COVERAGE LIMITS (actual policy wording will apply):
Our policies are designed with a few options in mind. The above is a summary of the standard policy and is not intended to be a policy of insurance or relied on. Please consult your insurance broker, your certificate of insurance and full insurance policy for your specific coverages, limits and deductibles.

This policy only provides coverage of up to $10,000 in contents and $25,000 in gross annual product sales.
NOTICE CONCERNING PERSONAL INFORMATION
I hereby consent to Dusyk & Barlow Insurance Brokers LTD, on behalf of LMI Canada Insurance to collect, use and disclose personal information required for the purposes of considering my application for insurance for new or renewal insurance coverage.

The Broker is authorized to collect, use and disclose personal information and provide such personal information to third parties, as required, including insurance companies. The Broker may also be required to disclose such personal information pursuant to relevant privacy laws or other laws. I authorize Dusyk & Barlow Insurance Brokers Ltd. to communicate directly with the member association.
WARRANTY STATEMENT
By submitting this Application, you attest that the application has been completed accurately and honestly. No disciplinary action has been or is pending against you. You have never been the subject of any investigation, either civil or criminal, in connection with any sexual act, conduct, molestation and/or assault. You understand that your insurance certificate will provide evidence that you have been added as an individual participant with respect to the coverage and limits of the Master Policy. You understand that the coverage provided by your insurance certificate is subject to all the terms, conditions and exclusions contained in the Master Policy. You further understand that the Insurance Company will rely on the information you have provided in the Application. Failure to pay required premiums and/or false statements on this Application or subsequent renewals shall void this Application and render your insurance coverage null and void and you may be subject to further legal action for making false statements.
Do you have a Commercial General Liability policy in place for your clinic?

YesNo
Please upload the certificate of insurance of your Commercial General Liability policy:

Cancelof
OFFICE CONTENTS INSURANCE POLICY

Please fill out the following questions
Applicant Name:*

First NameLast Name
Company or business name:*
Which of the following describes your business*

Corporation (Corp.)Limited(Ltd.)Sole Proprietor
Name of Owner(s)/Partners:*
What date did you or will you take possession of the space?*

MonthDayYear
Date
Location/Address of the business:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Square footage of the location:*
Number of employees:*
How many practitioners will be practicing out of the location?*
What is the estimated value of the contents you own/rent?*
What is the estimated value of the contents you own/rent?*
List operations and percent(%) of total sales carried out by employees or sub-contracted employees:*
Estimate total gross annual sales:*
What date is coverage required to begin?*

MonthDayYear
Date
Date Signed*

MonthDayYear
Date
Signature*

Clear
Please verify that you are human*
Should be Empty:

Association Application

Applicant Information

BUSINESS ACTIVITIES & UNDERWRITING QUESTIONS:

COMMERCIAL PROPERTY / WORK SPACES:

OFFICE CONTENTS INSURANCE POLICY

COVERAGE LIMITS (actual policy wording will apply):

NOTICE CONCERNING PERSONAL INFORMATION

WARRANTY STATEMENT

OFFICE CONTENTS INSURANCE POLICY