Smith Petrie Carr & Scott Insurance Brokers Ltd., Ottawa, Canada

Home : Products : ICCRC-CRCIC

Smith Petrie Carr and Scott Insurance Brokers Ltd.

iccrc-crcic Errors and Omissions Coverage

Application - Errors and Omissions Insurance for the Members of the Immigration Consultants of Canada Regulatory Council

Applicant Information

Mr.: Ms.:

First Name:

Last Name:

Member Number:

Are you a member in good standing:
Yes: No:

Billing Address

Address:

Suite Number:

City:

Postal Code:

Province/State:

Country:

Telephone Home:

Telephone Work:

Telephone Cell:

Email Address:

Mailing Address if different from billing address

Address:

Suite Number:

City:

Postal Code:

Province/State:

Country:

Applicant History

In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbally?:
Yes: No:

Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above?
Yes: No:
If yes, please attach details.

WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE INSURER, 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.

6. Limits Requested:

Limit Per Claim/Per Policy Period	Deductible	Premium	Taxes	Total
$1,000,000	$500	$145	$0	$0
All funds payable in $ CDN
I am not ordinarly a resident of Ontario and my office is located outside of Ontaio? Yes No

Subject to a policy aggregate of $5,000,000.

APPLICANT 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 ENCON Group Inc. for the sole purpose of obtaining an insurance policy, and will be kept confidential.

Moreover, I authorize ENCON Group 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.

For more information on ENCON's privacy policy, please contact privacy-officer@encon.ca.

DECLARATIONS AND SIGNATURE

The undersigned Applicant for this insurance declares that, to the best of his/her 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 further 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 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.

By submitting this form and making payment the applicant agrees to all terms and conditions.

Please forward payment by mail or call SPCS to supply a credit card number:

Please select Buy Now to submit the application with credit card payment. Select Print Page to send application along with a cheque payable to Smith Petrie Carr & Scott Insurance Brokers Ltd.

Contact Information
Telephone 613-237-2871
Facsimile 613-237-1179
Toll Free 877-432-5118

info@spcs-ins.com
www.spcs-ins.com

A Proud member of the Ontario Insurance Brokers Association