RCDSO Excess Malpractice Liability Insurance Program
Effective to January 1, 2019
 
(Claims Made and Reported Coverage)
Are you currently registered with RCDSO? *
Note: You must be RCDSO registered to be eligible for the 'Excess  Malpractice Liability Insurance Program'. If you wish  to become  a member,  please contact the RCDSO at 1-877-813-3757  or 416-934-5600.
Please complete this application in full, since it forms the basis upon which insurance is provided. In the event of a non-disclosure and/or misrepresentation, the policy may be voided at the option of the Insurer.
 
 
Primary Contact Details
Are you part of a Health Professional Corporation?
Have you had Excess Malpractice Liability coverage in the past? *
Select your choice for additional coverage above the mandatory $2,000,000 PLP limit.

Note: All figures are:
* Pro-rated for the balance of the policy period (3/4 of the annual premium)
* Net of tax
* Fully earned and Non-refundable *

PERSONAL INFORMATION CONSENT FORM

As part of the application for new or renewal insurance coverage(s), the Client hereby authorizes the Broker to collect, use and disclose personal information of such insured individuals as required and as permitted pursuant to relevant privacy laws or other laws.

The Client hereby expressly consents to the Broker collecting, using or disclosing personal information of such insured individuals, or providing such personal information to third parties as required, including insurance companies.  Where there are insured individuals in addition to the Client, or where the Client is a commercial or other entity, the Client hereby covenants and warrants that the Client has obtained the appropriate consent from all of the insured individuals to disclose their personal information to the Broker for these purposes.

I understand that if at any time I wish to review and/or obtain my personal information, or restrict the general nature of this consent to any specific area, from Jones DesLauriers Insurance Management Inc. I may make a written request to do so.  I may also request a copy of their privacy policies, make other enquiries, express concerns or file a complaint by contacting Jones DesLauriers Insurance Management Inc.’s Privacy Officer.  The Privacy Officer at Jones DesLauriers Insurance Management Inc. is:

 

Eric Osborne, Chief Operating Officer
Jones DesLauriers Insurance Management Inc.
Privacy Officer
416.259.4625
1.877.232.9996 x2352
markw@jdimi.com

By checking this box below, I have fully read and agree with the "PERSONAL INFORMATION CONSENT FORM" above. *

Thank you for completing the application.  Once submitted, we will provide a certificate of insurance confirming coverage is bound, along with invoice and payment options.

If you have questions or need assistance completing this form please contact our team below:
 
RCDSO Excess Malpractice Insurance Coverage
D 416.248.7144
F 416.259.7178 | 1.877.301.4979
excessprotection@jdimi.com
www.jdimi.com
 
 
Jones DesLauriers Insurance Management Inc.
2375 Skymark Ave.
Mississauga, ON
L4W 4Y6