Practitioners Professional Liability Insurance Application

Practitioner’s Professional Liability Insurance Application

This application is for a claims made policy

Please provide the following with the application

1. General Information

1. A) Name of Practitioner (Applicant):

(please show complete name as you wish it to appear on the policy)

B) Corporate Entity or Operating Name:

2. Address of Practice (Not P.O. Box):

Date Operations Began:

3. Coverage requested: $1,000,000 $2,000,000

4. Revenues: Last 12 Months: $   Next 12 Months: $

Number of Patient/Client Visits: Last 12 Months:   Next 12 Months:

5. Do you have patients/clients that reside outside of Canada? YES NO

If YES, please provide details and percentage of revenues attributed to these services:

2. Professional Services / Background Information

6. Specialization:

7. Other Services:

8. Qualifications:

9. Years of experience:

10. Regulatory or Licensing Body/Registration #:

3. Quality Control

11. Are records kept in accordance with your regulatory/licensing body? YES NO

12. Are quality control/risk management procedures in place? YES NO

4. Privacy

13. Do you collect, process or maintain private or personal information as part of your business activities? YES NO

If YES, please identify which Personal Identifiable Information is being held:

5. Network Security

21. Do your internal IT systems comply with the security requirements listed below: YES NO

22. Firewall protection systems to prevent unauthorized access to internal networks and computer systems? YES NO

23. Intrusion detection software to detect unauthorized access to internal networks and computer systems? YES NO

If YES, please list software being used:

24. Anti-Virus Software that is updated regularly? YES NO

25. Procedure to perform software updates within your network? YES NO

26. Monitoring of security vulnerabilities and appropriately patch systems and applications? YES NO

27. Backup of valuable/sensitive data on a daily basis? YES NO

28. Termination of computer access and user accounts as part of the regular exit process when an employee leaves the company? YES NO

29. Is personally identifiable information stored on laptop computers and portable media (flash drives, back-up tapes) protected by encryption? YES NO

6. Previous Insurance/Claims Information

30. During the last five (5) years, have you carried Professional Liability insurance? YES NO

If YES, please complete the following for all previous policies:

31. When was the first date on which you purchased continuous claims made coverage?

32. Have you ever been declined, non-renewed or cancelled by any insurer for Professional Liability insurance? YES NO

If YES, please explain:

33. Have you ever been disciplined by a licensing or regulatory body? YES NO

If YES, please explain:

34. In the last five (5) years, have you ever had a claim made against you? YES NO

If YES, please provide the following details on a separate sheet:

1) Date of claim    2) Claimant’s name    3) Nature of claim

4) Amount of indemnity payment and amount of defense costs    5) Final dispositions or current status of claim

35. Are you aware of any situation or circumstance which may reasonably result in a claim? YES NO

If YES, please describe in detail:

Without limitation of any other remedy available to the Insurer, it is hereby agreed that if there be knowledge of any such fact, circumstance or situation, any claim or action subsequently emanating therefrom is excluded from coverage under the proposed insurance.

7. Notice Concerning Personal Information

By purchasing insurance from Beazley Canada Limited, a customer provides Beazley with his or her consent to the collection, use and disclosure of personal information, including that previously collected, for the following purposes:

• the communication with underwriters;
• the underwriting of policies;
• the evaluation of claims;
• the detection and prevention of fraud;
• the analysis of business results;
• purposes required or authorized by law.

For the purposes identified above, personal information may be disclosed to Beazley's related or affiliated companies and service providers.

Further information about Beazley's personal information protection policy may be obtained by contacting their privacy officer at 416-601-2155.

8. Warranty Statement

The undersigned warrants that to the best of his or her knowledge, the statements set forth in this Application are true. The undersigned also warrants that they have not suppressed or misstated any material facts.

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 he or she will immediately report such changes to the Insurer.

Signing of this Application does not bind the undersigned to purchase this insurance, nor does it bind the Insurer to complete this insurance. However, should the Insurer bind and issue a policy, this Application shall serve as the basis of such contract and will be attached to and form part of the policy.