|
INTRODUCING FREE EXPRESS SERVICE. **
NEW ** |
|
***If you apply by 12
noon today you will receive your proof of malpractice liability insurance by
5pm today.*** |
|
Price: $135.00 Purchase NEW GRADUATE Policy (Annual prem. incl. $25 fee) |
| * By choosing this option, I certify that I have completed the requirements of registration with CMTO in the last 6 months. |
| * Designates mandatory fields. These MUST
be filled in. |
| Business/Clinic name (if applicable) |
|
| First Name |
* |
| Last Name |
* |
| Phone Number with Area Code |
* |
| Fax Number with Area Code |
|
| Email Address |
* |
| Verify Email Address |
* |
| Mailing Address |
* |
| City |
* |
| Province |
* |
| Postal Code |
* |
| Name of School graduated from: |
* |
|
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Coverage will be in effect the day after the application is received and accepted in our office. If you wish a different
start date please indicate here: |
| Example: Oct. 1 2008 |
|
|
Do you practice any modalities other than Massage Therapy? |
| No
Yes
|
|
|
Many RMT's find it convenient to have their
professional Liability insurance renew and paid for automatically each
year. If you would like to have your policy renewed and paid for automatically
in the future, with payment on your credit card check yes. If you would like to
receive a renewal notice by mail check no. |
| No
Yes
|
|
|
If you check yes to have your policy automatically renewed
please enter
your credit card number and expiry date.
BE SURE YOUR CREDIT
CARD IS GOOD FOR AT LEAST ONE YEAR.
(FAQ)
|
| * Must be credit card number with no spaces (16 digits), then space and expiry
(month year; 4 digits) |
| Example: 1234123412341234 0209 |
|
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Do you sell any products? |
| No
Yes
|
|
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Do you have any knowledge or information of any negligent act, any error or
omission, 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? |
| No
Yes
|
|
| If Yes to any of the above, please provide
details below: |
|
|
I am a new graduate applying for registration with the College of Massage Therapists of Ontario.
By submitting this application, you attest that the application has been
completed accurately and honestly. 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.
I Agree
I Disagree
|
| Note: this is just an order form; it does not
confirm insurance. If you require immediate documentation please provide your
fax number. |
