Cover Note Declaration Page - ATCMA



ATCMA Program – Preferred TCM Practitioners ProgramPROPERTY AND COMMERCIAL GENERAL LIABILITY APPLICATIONAPPLICANT’S LEGAL NAME: FORMTEXT ?????OPERATING NAME: FORMTEXT ?????NAME OF ALL SUBSIDIARIES AND AFFILIATES THAT INSURANCE IS TO BE INCLUDED: FORMTEXT ?????TYPE OF ORGANIZATION: FORMCHECKBOX Corporation FORMCHECKBOX Partnership FORMCHECKBOX Individual FORMCHECKBOX Other FORMTEXT ????? Operations of the Clinic include: FORMCHECKBOX Herbalist (R.TCM.H) FORMCHECKBOX Acupuncturist (R.Ac) FORMCHECKBOX Traditional Chinese Medicine FORMCHECKBOX Practitioners (R.TCM.p) and Doctors of TCM (Dr. TCM) FORMCHECKBOX Massage Therapy FORMCHECKBOX Acupoint Injection Therapy FORMCHECKBOX Supervised Students (s) if yes, how many ______Others: FORMTEXT ????? PHONE NUMBER: FORMTEXT ?????EMAIL: FORMTEXT ?????MAILING ADDRESS: FORMTEXT ?????INSURED LOCATION ADDRESS: FORMTEXT ?????WEBSITE: FORMTEXT ?????YEAR INCORPORATED: FORMTEXT ?????DATE COVERAGE REQUIRED: FORMTEXT ?????ATCMA MEMBERSHIP STATUS: Are you a member in good standing with the ATCMA? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide Membership No. FORMTEXT ?????CTCMA MEMBERSHIP STATUS: Are you a member in good standing with the CTCMA? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide Membership No. FORMTEXT ?????SUPERVISED STUDENTS: Do you supervise any students during their training sessions? FORMCHECKBOX Yes FORMCHECKBOX NoADDITIONAL PRACTITIONERS: Do you have any other practitioners working with you? FORMCHECKBOX Yes FORMCHECKBOX NoIf you are the principal of the clinic and have employees/independent contractors working in the clinic, please provide the following information: Name of PractitionerProfessional Designation(R.Ac, Dr. TCM, etc.)Does he or she carry Professional Liability insurance? (Yes or No)1. 2. 3. 4. CONTINGENT PROFESSIONAL LIABILITY: If you are the principal of this clinic, would you like to add Contingent Professional Liability insurance? This provides coverage in the event of a claim being made by one of your employees/independent contractors working in your clinic. FORMCHECKBOX Yes FORMCHECKBOX NoCONTINGENT PROFESSIONAL LIABILITY LIMITS: If you responded yes to the above, please advise the limits you would like to add: FORMCHECKBOX $1,000,000 FORMCHECKBOX $2,000,000 FORMCHECKBOX $3,000,000 FORMCHECKBOX $5,000,000 CONTINGENT PROFESSIONAL LIABILITY PREMIUMS: $1,000,000:$2,000,000:$3,000,000:$5,000,000: $1,100$1,452$1,755$2,420MANUFACTURING: Do you manufacture any products? FORMCHECKBOX Yes FORMCHECKBOX NoDo you undertake any work away from your business premises as stated above? FORMCHECKBOX Yes FORMCHECKBOX No LOCATIONLOCATION ADDRESS:Loc # FORMTEXT ?????Loc # FORMTEXT ?????Loc # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LOCATION OWNED/LEASED BY YOU: FORMCHECKBOX owned FORMCHECKBOX leased FORMCHECKBOX owned FORMCHECKBOX leased FORMCHECKBOX owned FORMCHECKBOX leased LOCATION LEASED/RENTED: If own the building you operate out of, do you lease or rent the space to others? FORMCHECKBOX rent FORMCHECKBOX leaseYEAR BUILT: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NO. OF STOREYS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CONSTRUCTION TYPELoc # FORMTEXT ?????Loc # FORMTEXT ?????Loc # FORMTEXT ????? FORMCHECKBOX Frame FORMCHECKBOX Concrete FORMCHECKBOX Fire Resistive FORMCHECKBOX Frame FORMCHECKBOX Concrete FORMCHECKBOX Fire Resistive FORMCHECKBOX Frame FORMCHECKBOX Concrete FORMCHECKBOX Fire ResistivePROTECTIONLoc # FORMTEXT ?????Loc # FORMTEXT ?????Loc # FORMTEXT ?????BUILDING SPRINKLERED:Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX % OF BUILDING SPRINKLERED FORMTEXT ????? % FORMTEXT ????? % FORMTEXT ????? %CONNECTED TO ALARM?Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX BURGLAR ALARM:Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX CENTRAL OR LOCALCentral FORMCHECKBOX Local FORMCHECKBOX Central FORMCHECKBOX Local FORMCHECKBOX Central FORMCHECKBOX Local FORMCHECKBOX PROPERTY INSURABLE VALUESBUSINESS COTENTS (including office contents, leasehold improvements, equipment, stock) LIMITS and PREMIUM: FORMCHECKBOX $25,000 ($110) FORMCHECKBOX $50,000($209) FORMCHECKBOX $75,000($303)(Value is based on Replacement Costs valuation except for Actual Cash Value on Stock) Others: FORMTEXT ????? *Note: Higher property limits are available. Please enter your desired limit under “Others” and BFL will provide you with the quote. REVENUESDESCRIPTION OF APPLICANT’S OPERATIONS AND ANNUAL SALES(Please breakdown by different services or product sales)Services/Product Sales Annual Revenue FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????COMMERCIAL GENERAL LIABILITY LIMITS REQUIRED: FORMCHECKBOX $1,000,000 FORMCHECKBOX $2,000,000 FORMCHECKBOX $3,000,000 FORMCHECKBOX $5,000,000COMMERCIAL GENERAL LIABILITY PREMIUMS: $1,000,000 $2,000,000$3,000,000$5,000,000$207$273$330$457CLAIMS HISTORY (Please provide details of all Losses in the past 5 years and (including legal defence costs)DATE OF LOSSCLAIMS STATUS (OPEN / CLOSED)DESCRIPTION OF LOSSRESERVEAMOUNT PAIDDEDUCTIBLE FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Are you aware of any other incidents which may result in a claim(s) against you? Yes FORMCHECKBOX No FORMCHECKBOX If Yes, please provide details: FORMTEXT ?????In the past, have you ever been the recipient of any allegations of professional negligence in writing? Yes FORMCHECKBOX No FORMCHECKBOX If Yes, please provide details: FORMTEXT ?????PREVIOUS POLICYPREVIOUS INSURER:POLICY NUMBER:EXPIRY DATE:POLICY TYPE: (PACKAGE, CGL, OR PROFESSIONAL)CLAIMS MADE OR OCCURRENCE FORM? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????In the past 5 years, has any Insurer refused, non-renewed or cancelled any liability policies? Yes FORMCHECKBOX No FORMCHECKBOX If Yes, please provide details: FORMTEXT ?????SIGNATURE Please sign below where indicated:I/We declare that statements made herein are in every respect true and correct and hereby apply for contract insurance to be based upon the truth of said statements. XXSignature of Signing Officer (Applicant)Title of Signing OfficerXXPrint Name of Signing Officers (Applicant)Date Signed:REV 08-2020 ................
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