i3 Wellness Application

Welcome to the i3 Wellness program, providing combined limits of Medical Malpractice and General Liability at competitive prices.

Please complete all mandatory fields including information on minimum one type of activity to receive your quote.

Please click on "submit" once you have completed the form. Your quote, contact and payment options will be provided to you via email.

Please make sure you enter the correct information as policies will be issued as they are entered below.

Thank you.

Broker Information

Email
*


Applicant Information

Name of Applicant(s)
(include all subsidiaries)
*
Mailing Address
*
Address (2)
City
*
Province/State
Postal Code
*
Website


Company Information

Date (Year) Company Established
*
Years of Experience:
*
Company Structure
*
Number of Directors,
Officers or Partners
Number of Employees *
  Professional:     Clerical:     Contractors:     Others:
What professional associations
does the applicant belong to?
List any legislation in force which govern the applicant's operation.
Yes  No   
Are all Employees covered by WCB?? *
Yes  No   
Have you ever had any restriction of limitation imposed upon any licence that you hold or been the subject of any disciplinary action by any licensing body? *


Company Information

 
Last 12 Months or Last Fiscal Year
Anticipated Next 12 Months or Next Fiscal Year
Canadian Revenue
 
*
USA Revenue
Foreign Revenue
Profit / Loss
Date of Company Financial Year End:
*


Operations

Breakdown of total revenue by activity, including product sales & training operations.

Search & Add Operations

Filter By Category

Animal Services
Beauty, Spa & Medi Services
Conventional & Alternative Medicine
Counselling, Coaching & Therapy
Massage Services
Nutritionist & Health Coach
Other
Spiritual Therapy & Energy Healing
Sports & Fitness

Keywords:
Results:

Operations Included In This Policy

Yes  No   
Does the Applicant perform any activities other than those listed in the Operations section above? *
Yes  No   
Are there any online operations (platforms include but are not limited to YouTube, Zoom, etc.) that the Applicant uses as a part of their business operations? *

Please confirm the following:

Yes  No   
Does the Applicant conduct criminal background checks on all Individuals/ Contractors prior to their employment? *
Yes  No   
Does the Applicant verify the professional qualifications of all individuals/ contractors prior to their employment? *
Yes  No   
Does the Applicant obtain confirmation from all individuals/ contractors for employment that they have not had any claim made against them at any time? *
Yes  No   
Does the Applicant obtain confirmation that all independent Contractors maintain their own medical malpractice liability insurance? *

Check all that apply:

Yes  No   
On average, do more than 80 patients visit per day? *
Yes  No   
Are records maintained for the services provided to clients? *
Yes  No   
Are Waivers of Liability used with all clients? *
Yes  No   
Does the Applicant provide any treatment to minors? *


Claims History

Regarding all of the types of insurance to which this application from relates, AFTER ENQUIRY:

Yes  No   
Are you aware of any loss or damage, whether insured or not, that has occurred to any of the Companies to be insured (or to any existing or previous business of the partners or directors of any of the Companies to be insured) within the last 5 (five) years? *
Yes  No   
Are you aware of any circumstances which may give rise to a claim against any of the Companies to be insured or any partners or directors thereof? *
Yes  No   
Have any claims or cease and desist orders been made against any of the Companies to be insured, or any partners or directors thereof? *
Yes  No   
Have any partners or directors of the Companies to be insured been found guilty of any criminal, dishonest or fraudulent activity or been investigated by any regulatory body? *


Insurance Requirements & History

Required Limit:
Retroactive Date:
Effective Date:
*
Date Quote Required:
*
Date Application Signed:


Additional Information

A signed application is required to be submitted. Click here to print this form.

Please attach any relevant documentation to allow us to process your request, e.g. certificates, expiring documentation if requesting retroactive cover, etc.

Application:
 

 
Please provide any additional information

 


Signature

NOTICE TO APPLICANT:

I/we declare that the best of my/our knowledge and believe the answers given on this application whether by me/us or on my/our behalf are complete and true and that I/we have not withheld any material information.

If this application has been completed on my/our behalf, I/we agree the person is deemed to be my/our agent and not an agent for the Insurer and I/we have read the information provided before signing the form.

This application must be signed by a principal, director, or partner of the proposed First Named Insured.

Consumer and previous insurer reports containing personal, credit, factual or investigative information about the applicant may be sought in connection with this Applicant for Insurance or any renewal, extension, or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of Insurance. The policy may be deemed to be void and claims may be denied where:

  • An applicant for a contract:
    • Gives false or erroneous information to the prejudice of the insurer, or
    • Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or
  • The Insured contravenes a term of the Contract or commits a fraud; or
  • The Insured willfully makes a false statement in respect of a claim under the contract.

I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE, I AM AUTHORIZED TO CONTRACT ON BEHALF OF THE INSURED, AND I APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THESE STATEMENTS.

I AM IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE CONTRACT.



Signature of Applicant

Position

Please print name

Date