This policy will include: $25,000.00 Contents of Every Description All Risk, New Replacement Cost - $1,000.00 Deductible Sewer Backup is included in Ontario with a $2,500.00 Deductible Covers your furniture, equipment, improvements you make to the space and other property owned by you or for which you are legally liable. $50,000.00 Extension Package Covers items such as glass, outdoor signs, property in transit, contents temporarily at unnamed locations (22 items), $500.00 Money Coverage. $50,000.00 Business Interruption Loss of income due to an insured loss. Crime Insurance Employee dishonesty. Robbery. $25,000 Contents of Every Description rd Includes Bodily Injury to a 3 Party, $250,000.00 Tenants Liability. The above is a description of the coverages only. Please refer to the policy for specific coverages and limits. Application for OFFICE CONTENTS Insurance Policy Please complete this section: COMPANY OR CLINIC NAME: ______________________________________________________________________________________________ NAME OF OWNERS/PARTNERS: ___________________________________________________________________________________________ ADDRESS OF CLINIC: ____________________________________________________________________________________________________ MAILING ADDRESS (IF DIFFERENT THAN ABOVE): ____________________________________________________________________________ CITY: ________________________________________________ PHONE: _________________________ PROVINCE: __________________ CELL: _________________________ POSTAL CODE: __________________ EMAIL: ____________________________________________ I declare to the best of my knowledge, the information provided by me is true and complete and Novex Insurance may rely on it in issuing coverage to me. I currently have a professional liability package in place with Lackner McLennan Insurance as I understand that this policy is contingent on maintaining my professional liability. Signature X ________________________________________________________ Date X _________________________________________ PLEASE NOTE: This policy expires May 1st of each year. PREMIUM LIST Please choose the application premium: MAY JUNE JULY AUGUST SEPTEMBER OCTOBER $270.00 $249.00 $228.00 $207.00 $186.00 $165.00 NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL $144.00 $124.00 $102.00 $81.00 $70.00 $70.00 PREMIUM CALCULATION Premium Charged (from chart above) Annual Policy Fee RESIDENTS OF ONTARIO – add 8% PST TOTAL PREMIUM PAYABLE PST $ $25.00 $ $ Please make your cheque payable to Lackner McLennan Insurance. If you wish to pay by credit card, please provide information below. Coverage will be in effect the day after your application is received and approved in our office. CREDIT CARD PAYMENT – If you wish to pay by VISA OR MASTER CARD, please provide information below: Credit Card # Expiry Date Signature of Cardholder Signature X ________________________________________________________ Date X _________________________________________
© Copyright 2024