Choose one of the following 3 options:
* 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.)
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
Name of School graduated from:
College Registration Number
Do you practice any modalities other than Massage Therapy?
No
Many RMT's find it convenient to have there
professional Liability insurance renew automatically each
year. If you would like to have your policy renewed automatically
in the future, with payment on your credit card check yes. If you would like to
receive a renewal notice by mail check no.
No
If you check yes to have your policy automatically renewed
please enter
your credit card number and expiry date. (FAQ)
* Must be credit card number with no spaces (16 digits), then space and expiry
(month year; 4 digits)
Do you sell any products?
No
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
If Yes to any of the above, please provide
details below:
I am an active member in good standing with the
College of Massage Therapists of Ontario
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
if making false statements.
I Disagree
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).
