CMMOTA Renewal Form

Renewal Form

Liability insurance for the members of the Canadian Massage & Osteopathic Therapist Association.
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
POLICY INCLUDES:
Our policies are designed with a few options in mind. The following 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:
- $$5,000,000 Professional Liability – Otherwise known as Errors & Omissions Insurance, covers your liability for errors and omissions or
  negligence during the course of your insured professional services. If a third party, such as a client, brings a suit against you for damages
  covered by your insurance policy, this protection would also cover legal fees for your defense. Subject to the wordings of your policy.
- $100,000 Legal Expense Coverage – Provides protection for your insured business from claims by third parties, such as clients or other
  businesses, which allege sexual, physical, or verbal abuse. This coverage will reimburse you for legal expenses in the defense of an
  allegation, provided you plead not guilty and are found not guilty. This excludes criminal defence costs. Subject to the wordings of your
  policy. Claims must be reported within 60 days of being notified of an allegation.
- $10,000 Criminal Defense Cost Reimbursement – If a criminal proceeding is brought against you due to your insured professional services
  you may be eligible for criminal defense cost reimbursement. This coverage applies if such proceeding arises because of the manner in
  which you have conducted yourself within your Practice and only if the defence of such action, suit or proceeding is fully successful (you
  plead not guilty and are found not guilty). Subject to the wordings of your policy.
- $5,000,000 Commercial General Liability – Commercial general liability insurance protects you and your insured business against claims
  for bodily or personal injuries, advertising liability. This coverage also includes property damage to third parties arising from your
  operations or products or occurring on your business premises. In the event of an insured claim against you this coverage would cover
  legal costs to defend the claim against your business in court, as well as damage rulings against you to compensate third parties. Subject to
  the wordings of your policy.
- $500,000 Tenants Legal Liability – If you or an employee unintentionally cause damage to the property you are renting you may be legally
  responsible for these damages. If insured, Tenants Legal Liability would provide funds to your landlord to facilitate repairs to the building.
  This coverage does not extend to your personal equipment. Subject to your policy wordings.
- Legal Guard-24/7 Telephone access to legal information service for questions relating to your business.
  This policy allows up to $25,000 in PRODUCT SALES. Products must relate to your modality, they cannot be self-manufactured,
  tampered with, nor relabeled. Products can only be sold to existing clients.
This policy allows up to $25,000 in PRODUCT SALES. Products must relate to your modality, they cannot be self-manufactured, tampered with, nor relabeled. Products can only be sold to existing clients.
ADDITIONAL MODALITIES:
We can ensure more than 365 modalities, however, your policy only insures you for the modalities listed on it. If you practice other modalities you must advise us, so we can determine whether or not it can be included on this policy. Please note some modalities are subject to additional premiums.

Please list any new modalities you have begun practicing since last renewal. If you practice Esthetics, you must list all the services you provide under this modality. Please note some modalities have additional premiums and we will contact you if any additional premium is required. Certificates of training must be submitted for any new modalities that have not been previously reported to us. If any questions on the current list of modalities you are approved for, please contact your association office.
List any new modalities of your practice:
Please upload certifications for each modality you have listed above:

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Do you sell or manufacture any products?

YesNo
If ‘yes’, please explain, and please note you can only sell a maximum of $25,000 of products in any one calendar year:
This policy only provides coverage of up to $10,000 in contents and $25,000 in gross annual product sales.
Please advise if your business structure has changed in the last 12 months ( Leased a Commercial space, hired employees/sub-contractors, Incorporated yourbusiness name, just to name a few):
COVERAGE LIMITS:
This INDIVIDUAL LIABILITY POLICY is designed to cover you as an individual practitioner and is not intended to cover Employees, Sub-Contractors, Business Partners or a Commercial Office space you may be renting over 200 SQFT. The Insurance limits of this individual policy are not sufficient for business practices that fall outside these parameters. If your practice falls outside these parameters please contact Dusyk & Barlow Insurance Brokers Ltd.
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 own a clinic that leases more than 200 sq ft of space, employs or contracts practitioners other than yourself or have more than $10,000 of contents?

YesNo
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:*

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OFFICE CONTENTS INSURANCE POLICY

Please fill out the following questions
Applicant Name*

First NameLast Name
Company or Business Name: *
Name you are operating as
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?*
Provide a brief description of contens and how they relate to your practice:*
List operations and percent(%) of total sales carried out by employees or sub-contracted employees:*
Estimate total gross annual sales:*
Date Signed*

MonthDayYear
Date
Signature*

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

Renewal Form

Applicant Information

POLICY INCLUDES:

ADDITIONAL MODALITIES:

COVERAGE LIMITS:

NOTICE CONCERNING PERSONAL INFORMATION

WARRANTY STATEMENT

OFFICE CONTENTS INSURANCE POLICY