Counsellors Professional Liability Insurance Application

Counsellors and Practitioners Professional Liability Insurance Renewal Application

Here's the additional information we need to quote your Professional Liability Renewal!
Please confirm the full legal name of your company to be shown on the Certificate of Insurance*
If you are operating as a sole proprietorship (i.e. without Inc., Ltd., LLC etc...), please include "operated by" or o/b followed by your first and last name after the company name.
Kindly just confirm the Best Email to reach you*

We just need it to match up for your completed application with the file we've already started for you!
Has your Contact Information and/or Business Address changed since the last renewal?*
Please provide the new address or contact information to be used.
Have your Operations or Professional Services / Modalities changed since your last renewal?*
Please provide a brief description of the changes made to your operations.
The more details the better!
Have you any knowledge of any negligent act, error or omission and or breach of duty, which may give rise to a Claim against you?*
What is the date of loss of the claim/incident?
Month
Day
Year
Please provide a brief description of the claim/incident, the amount paid, reserved and/or if it is open or closed.
The more details the better!
Do you work with Professional Athletes?*
Please provide your total revenue*
Please enter a number greater than or equal to 0.
% of total revenue from Canadian patients*
Please enter a number from 0 to 100.
% of total revenue from US patients*
Please enter a number from 0 to 100.
% of total revenue from World Wide patients*
Please enter a number from 0 to 100.
Please indicate the number of sub-contractors or other practitioners that practice in your business?*
Please enter a number from 0 to 100.
If you are not a sole proprietor, do your employees carry professional liability insurance?*
Is there anything else you'd like to share with us or think we should know about you, your operations, the risk etc.?
Declaration*
I declare that the statements and particulars contained in this Renewal Declaration are true and that I have not mis-stated or suppressed any material facts. I agree that this Renewal Declaration together with any other information supplied by me shall form the basis of any contract of insurance effected thereon. I undertake to inform Insurers of any material change to these facts occurring before completion of the contract of insurance. However, the duty to disclose material facts continues after the completion of the Renewal Declaration and throughout any period of insurance (and any extension thereto), upon which this Renewal Declaration was used as the basis of the contract of insurance.
Consent*
I accept and confirm that I have verified the information supplied and that it accurately reflects the details of the company applying for insurance. Additionally, I authorize the use of this information to attempt to secure insurance quotes on my behalf and agree that I can contact by ALIGNED Insurance Ltd. regarding insurance matters.

Counsellors and Practitioners Professional Liability Insurance Renewal Application

Here's the additional information we need to quote your Professional Liability Renewal!