**New Lower Rates for 2008**
Applying and renewing online is fast and easy! Your policy must be
renewed prior to the expiry date. If you have had a change of address or
other critical information since your last renewal please click
HERE and fill out the Change Of Essential Information Form before
filling out this application. |
| * Choose one of the following 2 options: |
Price: $243.00 ($200 + $25 policy fee + 8% pst. Ontario only)
Price: $225.00 ($ 200 + $25 policy fee, All other
provinces) |
* 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. RENEW RAC
Policy (Ontario Residents - includes 8% PST) |
| 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 |
* |
| RAC Registration Number |
* |
| Do you practice any modalities other than Reflexology? |
| No
Yes
|
|
| Do you sell any products? |
| No
Yes
|
|
| 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 an active member in good standing with the
Reflexology Association of Canada.
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. Your policy must be renewed prior to the
expiry date. If your expiry date has passed please contact the office at
1-877-RMT-CANADA (1-877-768-2262). |
