PROFESSIONAL LIABILITY INSURANCE DECLARATION for the Registration Year of April 1, 2015 to March 31, 2016 The Social Work Profession Act (Regulation, Section 22) requires that every Practicing registrant who holds a Certificate of Practice must be covered by, and maintain, professional liability insurance coverage (through employer or independently). The College Board of Directors has set the required minimum value of insurance at $2,000,000. As an individual who has applied for or currently holds a Certificate of Practice with the Manitoba College of Social Workers, I declare that: • • • • I currently carry professional liability insurance at a minimum value of $2,000,000 for each position in which I function as a social worker. I agree to notify the Manitoba College of Social Workers, in writing and within 30 days, in the event that I am no longer covered by the required professional liability insurance. I agree to provide evidence of professional liability insurance upon request by the Manitoba College of Social Workers. I understand that providing false or misleading statements, representations or declarations to the Manitoba College of Social Workers constitutes unprofessional conduct and is cause for denial, revocation, suspension or cancellation of registration with the Manitoba College of Social Workers. Name: ________________________________________ (please print) Date of Birth: ____________________ (d/m/y) Signature: _______________________________________ Date: ___________________________ Please submit a copy of this form to: Manitoba College of Social Workers, 101 – 2033 Portage Avenue, Winnipeg, MB R3J 0K6 Phone: (204) 888-9477 Fax: (204) 831-6359 Email: [email protected] Website: www.mcsw.ca 15 05 2015