If your
renewal date is past (policy is expired) click HERE. |
| * Choose one of the following 3 options: |
|
Price: $199.80 RENEW RMT Policy (Annual premium incl. $25 fee). |
|
Price: $105.30 RENEW
RMT Policy (6 month premium incl. $17.50 fee) |
| * If
you wish to renew for a 6 month term the rate will be $105.30. Save $10.00 by renewing now for one year. There will be no increase in the annual premium. |
|
Price: $415.80 RENEW RMT Policy plus Acupuncture (Annual premium incl. $25 fee) |
| * Designates mandatory fields. These MUST
be filled in. If you have no email address please enter "none" and you will NOT receive
email notification of this transaction. |
| Business name (if applicable) |
|
| First Name |
* |
| Last Name |
* |
| Street Address |
* |
| City |
* |
| Province |
* |
| Postal Code |
* |
| Phone Number with Area Code |
* |
| Fax Number with Area Code |
|
| Email Address |
* |
| Verify Email Address |
* |
| |
|
| Your Web Page WWW. |
|
| Name of School graduated from: |
* |
| College Registration Number |
* |
| * If you have no email address
please enter "none" and you will NOT receive email notification of
this transaction. |
Please check all locations from which you practice
Massage Therapy: |
| From your home
|
Chiro/Physio Clinic etc.
|
| Massage/Wellness Clinic
|
Spa
|
|
|
| Do you practice any modalities other than Massage Therapy? |
| No
Yes
|
|
| Many RMT's find it convenient to have there
professional Liability insurance renewed and paid for automaticallyy 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 |
|
| 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: |
|
I am an active member in good standing
with the College of Massage Therapists of Ontario. (or I am
applying to have my registration reinstated in the next 10 days)
By submitting this application, you attest that the application has been
completed accurately and honestly. No disciplinary action has been taken 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.
I Disagree
I Agree
|
| Note: this is just an order form; it does not
confirm insurance. If you require immediate documentation please provide your
fax number. |
