AAATCMD Application

  • Application Form

    Errors & Omissions, Commercial General Liability, and Property Insurance for members of the Alberta Association of Acupuncturists and Traditional Chinese Medical Doctors

  • THE APPLICANT

  • Format: (000) 000-0000.
  • 3. Are you a member in good standing with the College of Acupuncturists of Alberta as a registered acupuncturist?*
  • 5. Have you ever been investigated by or suspended from practice by any governing body of your profession?*
  • 6. Do you provide services or perform activities outside Canada or for clients outside Canada?*
  • 7. Have you ever had insurance coverage declined, cancelled, or renewal refused?*

  • Acupuncture
    Acupressure
    Alexander Technique
    Aromatherapy
    Auricular therapy
    Bach remedies
    Colour therapy
    Craniosacral therapy
    Crystal therapy
    Ear candling
    Ear seed
    Electro acupuncture
    Energy Healing – (Spiritual healing, Psychic healing, Therapeutic touch, Healing Touch, Hands of light, Esoteric healing, Magnetic healing (now a historical term not to be confused with magnet therapy), Qigong healing, Reiki, crystal healing, Tong Ren therapy, Distant healing, Intercessory prayer)
    Fire Cupping
    Guasha
    Healing/reiki
    Herbalism – consulting only, no product sales
    Iridology
    Jin Shin Do and Jin Shin Acupressure
    Light touch therapy
    Low level laser
    Moxibustion
    Magnetic therapy
    Nutrition therapy
    Nasya sinus
    Plum blossom needling
    Qui gong
    Reflexology
    Rolfing
    Reiki
    Shiatsu
    Sound Therapy (when in conjunction with other therapies but if exclusively sound must be referred)
    Somatic experiencing
    Tuina
    Therapeutic touch

  • 9. Have you been previously insured by the College E&O (policy SRD539937 issued by Victor Insurance Managers)?
  • 10. a) In the past, have you or any of your employees ever been the recipient of any allegations of professional negligence in writing or verbally?
  • 10. b) Are you or any of your employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above?

  • WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURERS, IT IS 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.

  • LIMITS OF INSURANCE REQUESTED

    *Note: You will be asked to reconfirm limits at time of payment. The limits selected at time of payment are binding.
  • 11. a) Errors and Omissions Insurance*
  • 11. b) Commercial General Liability Insurance*
  • 12. Business Contents Insurance*
  • 13. Do you have any piece of business equipment that is valued at $10,000 or more?
  • 14. Have you had a business property/equipment breakdown claim in the past 3 years?

  • APPLICANT'S CONSENT TO THE TRANSMISSION OF THE INFORMATION CONTAINED IN THE APPLICATION FORM

  • I hereby acknowledge that the information collected in the Application form is acquired by my insurance broker to be transmitted to Victor Insurance Managers Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential.

    Moreover, I authorize Victor Insurance Managers Inc., its insurers or service providers to:

    • conduct verification, using outside sources, of the information contained in the Application form, in attached documentation and in subsequently provided documentation;
    • in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar offices for the purposes of investigating, defending, negotiating or settling any claims, as required.

    Email privacypolicyinquiries@victorinsurance.com for more information on Victor’s privacy policy.

  • DECLARATIONS AND SIGNATURE

  • The undersigned Applicant for this insurance declares that, to the best of their knowledge and belief, the statements set forth herein are true and correct, and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The undersigned agrees that if any significant change in the condition of the Applicant is discovered between the date of this Application form and the effective date of the policy, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Insurance Manager.

    Although the signing of this Application form does not bind the Applicant to purchase the insurance, the undersigned Applicant further agrees that this form and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this form will become part of the policy.

  • Report claims via email to newclaims.ca@victorinsurance.com.

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