Name: Excess Malpractice Liability
SKU: 334
Availability: InStock

$70.50 – $791.50

Your College Registration Number: *Forgot your College ID?
Effective Date of Policy: *
LimitSelect your choice for additional coverage above the mandatory $2,000,000 Professional Liability Program limit.Limits and Premium Choices
QuarterLimits and Premium Choices	Clear
Add Legal Expense Coverage? *Covers legal expenses to defend and/or pursue legal action against a third party. Annual premium $165.00 Learn More	Yes No
Add Excess Liability Coverage? *This coverage is in excess of the Primary Malpractice Liability Per Occurrence Limit of $2,000,000 which is included as part of your registration with the Royal College of Dental Surgeons of Ontario. Learn More	Yes No
Would you like to renew your Legal Expense Insurance policy? *	Yes No
Would you like to renew your Excess Malpractice Liability policy? *	Yes No
Time Zone: *

Excess Malpractice Liability Limit
Select a Limit: *What Limit Should I Purchase?

Premium*

*Incl $55.00 Agency Fee

Premiums are pro-rated depending on your effective date, subject to a minimum retained amount.

Policy Effective [] to

Primary Contact Information
NOTE: Your details will appear exactly as entered on your documentation. Please type carefully.
First Name: *Do not type "Dr." as it is already included.
Surname: *
Email: *IMPORTANT: Do not use a generic email address such as "info@" or "admin@" to ensure email deliverability.
Phone: *
Business Tel:

Business Contact Information
NOTE: Your details will appear exactly as entered on your documentation. Please type carefully.
Professional Designation:
Licensed Since (YYYY):
Address: *
City: *
Province: *
Postal Code: *

Please Answer the Following:
Have you had 1 or more legal issues in the past 3 years? * (If yes, you will be contacted before being able to purchase Legal Expense Liability.)	Yes No
Would you like an invoice in the name of your Health Professional Corporation? *	Yes No
Please enter the name of your Health Professional Corporation: *
Are you planning on retiring this year? *	Yes No
Date of Retirement: *
Have you had Excess Malpractice Liability coverage in the past? *	Yes No
By clicking ‘I agree’, it is acknowledged that you have read and agree with the Personal Information Consent Form.	I Agree
Has there been, or are there now pending, damages against you that have not been reported to the Professional Liability Program? *(If yes, you will be contacted before being able to purchase Excess Liability.)	Yes No
Are you aware of any fact, circumstance or situation which may give rise to a Claim under the policy to which this application will be attached? *(If yes, you will be contacted before being able to purchase Excess Liability.)	Yes No
View Warranty Statement
By clicking ‘I agree’, it is acknowledged that you have read and agree with the Warranty Statement.	I Agree

SKU: N/A Category: Uncategorized

RCDSO Excess Malpractice Liability Insurance Program

Personal Information Consent Form