Are you RENEWING your Errors & Omissions Insurance under the ICCRC Program?
If you chose "No" and are therefore purchasing coverage for the first time please answer the two following questions.
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.
Subject to a policy aggregate of $10,000,000.
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 Victor Canada for the sole purpose of obtaining an insurance policy, and will be kept confidential.
Moreover, I authorize Victor Canada, 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.
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.
In the event of a claim or circumstance, I agree and consent to any information and documentation relating thereto to be released and disclosed to Immigration Consultants of Canada Regulatory Council (ICCRC) for the purpose of enabling ICCRC to carry out its responsibilities and functions under the letters patent, bylaws and regulations of ICCRC
By submitting this form and making payment the applicant agrees to all terms and conditions.
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.
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