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 _________________________________________