Clinical Trials Application Form
Broker Information
Broker Name
*
First Name
Last Name
Broker Email:
*
example@example.com
Broker Phone Number:
*
Format: (000) 000-0000.
Brokerage
Applicant Company Information
Company Name / Named Insured:
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Address (if differs from Mailing)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website Address:
List any subsidiaries for whom coverage is required:
Coverage will not be provided for subsidiaries unless listed and agreed upon.
Company Contact Information
Please provide the primary company contact for this application.
Name
First Name
Last Name
Email:
*
example@example.com
Phone Number:
Format: (000) 000-0000.
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Required Trial Documentation
Important: A copy of the clinical trial protocol and informed consent form must be provided with this application.
Please attach the following:
Clinical trial protocol
Informed consent form
Any additional supporting documentation relevant to the trial
File Upload
Browse Files
Drag and drop files here
Choose a file
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Trial Location Information
Please confirm all countries where the clinical trial is taking place.
Country or Countries:
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Enrolled Patient Numbers by Country
Please provide the number of enrolled patients for each country where the trial is taking place.
Total Number of Enrolled Patients:
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Policy Period Required
Please confirm the policy period required. Coverage may be available for a policy period of up to 10 years, subject to underwriting review.
Requested Policy Start Date:
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Requested Policy End Date:
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Requested Policy Period:
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The completion and submission of this application to the Company does not constitute a promise to provide coverage or a binder of insurance.
If the information provided in this application should change between the date of the application and the effective date of the policy, the undersigned warrants that they will immediately report such changes to the insurer.
The completion and signing of this application does not constitute a promise to provide coverage. However, if a policy is issued, this application shall serve as the basis of such contract and will be attached to, and form part of the policy.
THE UNDERSIGNED HEREBY ACKNOWLEDGES THE TRUTH OF THE STATEMENTS CONTAINED HEREIN.
I AUTHORIZE YOU TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION AS PERMITTED BY LAW, IN CONNECTION WITH YOUR COMMERCIAL INSURANCE POLICY OR A RENEWAL, EXTENSION OR VARIATION THEREOF, FOR THE PURPOSES NECESSARY TO ASSESS THE RISK, INVESTIGATE AND SETTLE CLAIMS, AND DETECT AND PREVENT FRAUD, SUCH AS CREDIT INFORMATION, AND CLAIMS HISTORY.
For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd's Underwriters' insurance business in Canada.
Signature of Applicant (authorized representative)
Date
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Confirm Form is Complete
Yes
Submit
BOS JotForm Submission Key
BOS JotForm Redirection
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