PROFESSIONAL AND GENERAL LIABILITY FOR REGISTERED MASSAGE THERAPISTS
Please enter your information into the shaded areas below.


Applicants Name   Email
Mailing Address   Postal Code
Daytime Phone   Evening Phone
If you wish to have a copy of your certificate faxed to you, please enter fax number here 
PLEASE COMPLETE THE QUESTIONS BELOW: 
Do you practice Acupuncture or Traditional Chinese Medicine?  Yes   No
Do you practice any other complementary modalities, e.g. reflexology, aromatherapy, cranial sacral? Please attach copy of certificate.  Yes   No
Do you practice any modalities that fall outside the scope of practice as defined by the CMTO?
(Allergy testing, bach flower therapy, homeopathy, orthotics, osteopathy etc.) 		 Yes   No
Do you blend or manufacture any products or devices?  Yes   No
Do you have any knowledge or information of any negligent act, any error or omissions, or breach of duty that might give rise to a claim against you, or any reason to anticipate that a claim might be brought against you?  Yes   No
Provide details of all liability losses in the past 3 years.  If none, check here
IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS,
PLEASE PROVIDE DETAILS ON A SEPARATE SHEET AND ATTACH TO THIS APPLICATION.
Your policy will include:
$3,000,000 Professional Liability
$25,000 Legal Expense
$2,500 Office Coverage (Including contents, loss of income, theft of money etc.)		$3,000,000 General Liability
$250,000 Tenants Legal liability
(Please see the policy for a complete list of coverages)
Coverage will be in force the day after this application is received and accepted in our office.
If you wish a different date, please indicate it in the box to the right.
Annual Policy$199.80 (Includes $25.00 policy fee)
Six Month Policy $105.30 (Includes $17.50 policy fee)
Student Policy
The BEST deal for Students in Canada!		 $135.00 (Includes $25.00 policy fee)
For Students Policy ONLY:
By choosing this option, I confirm that I have successfully completed the certification examinations required by the CMTO within the last 6 months. Check here
IF YOU ARE PAYING BY VISA/MASTER CARD PLEASE COMPLETE:
Cardholder agrees to pay total amount shown to card issuer according to Cardholder Agreement.
Card Number   Exp.   Signature   
IF YOU WISH TO HAVE YOUR POLICY RENEWED AUTOMATICALLY EACH YEAR USING CREDIT CARD NUMBER ABOVE,
PLEASE CHECK HERE

*Click on the in your browser, OR select File-->Print... from the browser menu to print your information entered above,
and return it with your payment.

PLEASE RETURN THE COMPLETED / SIGNED APPLICATION AND PAYMENT TO:
Lackner McLennan Insurance Ltd
LACKNER MCLENNAN INSURANCE LTD.
423 KING STREET NORTH
WATERLOO, ON N2J 2Z5
FAX 1-519-579-1151

Questions?
If your question isn't answered below, please contact us by email: rmt@lmicanada.com