2014 December to Application for

Application for
Membership Upgrade
August
December
to
for current Associate
members who have
completed training and
require full insurance
2014
Vision
Wellness through natural health.
Mission
We champion professional excellence to support
the growth of natural health and wellness.
Values
We believe in and support choice, competency, efficacy,
inclusivity, integrity, and responsiveness
6TH FLOOR, 10339
email: [email protected]
1toll-free:
2 4 S T1-888-711-7701
, EDMONTON, AB T5N 3W1
fax: 780-484-3605
Application for Membership Upgrade
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Required Documents (submit with this application)
a copy of your certificate/diploma of completion and official transcripts for an NHPC recognized program and/or a copy of
your certificate of membership for an NHPC recognized association
a copy of your Municipal License, if required to practise in your municipality
If your certificate/diploma or municipal license (if applicable) are not attainable at the time you submit this application, you
must submit them within 30 days of the date in which this application for membership is received at the NHPC. If the abovelisted documents are not received within that 30 days, your membership will be revoked.
if you are currently registered with a provincially legislated massage therapy regulatory body (CMTBC, CMTO, or NLMTB),
provide a copy of your registration
if the name on this application is different than the name on the documents submitted with it, provide proof of name change
Language Preference:
English
French
Male
Female
Personal Information (required)
First Name
Initial
Last Name
Address
City
Home Phone
Province
Postal Code
Email (used for your website member account login and confidential communications)
NHPC Membership Number
Cell Phone
Fax
Birthdate (MM/DD/YYYY)
Gender:
Business Information (required)
Business Name
Address
City
Email (used for public communications)
Phone
Province
Postal Code
Fax
Website
Preferences (required)
Send me information on NHPC benefit partner programs (discounted products and services):
Yes
No
Send me the yearly catalogue for the NHPC Centre for Learning (NHPC learning opportunities) by:
Email
Mail
Send me the yearly brochure for the NHPC Annual National Conference by:
Email
Mail
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: [email protected]
Page 1
of 6
Application for Membership Upgrade
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Current or Planned Practice (required)
Do/will you complete a preliminary assessment to identify contraindications to services?
Yes
No
Do/will you obtain a signed waiver from clients acknowledging disclosure of limits, contraindications, and
possible side effects of services to be provided?
Yes
No
Do/will you adhere to informed consent within your regular practice at all times?
Yes
No
Do/will you sell products as part of your practice (oils, lotions, aromatherapy products)?
If so, please list:
Yes
No
Have you ever pled guilty to or been convicted of a criminal offense for which you have not been
pardoned?
Yes
No
Have you ever been subject to a professional conduct disciplinary process or been disciplined by a
professional body?
Yes
No
In what type of setting do/will you practice, if known? (check all that apply)
Private practice in clinic or office
Private Practice in home
On-site (company or client's home)
Fitness centre, spa, or health club
Resort or hotel
Other:______________________________________
Sports medicine facility
Chiropractic or physiotherapy office
Group practice-rehabilitation
Holistic health centre
Hospital, nursing home, or hospice
Legal (required)
NHPC Privacy Statement
To assist the NHPC in providing and improving member services, for public protection purposes, and advocating on your behalf,
the NHPC requires your consent for the collection, use, and disclosure of your personal information for such purposes, and in
accordance with the NHPC Privacy Policy and the NHPC Bylaws and Code of Ethics. A copy of the NHPC Privacy Policy is
posted on the NHPC website (www.nhpcanada.org). A copy will also be enclosed with your new member package. By signing
this application, I consent to the collection, use, and disclosure of my personal information in accordance with the
NHPC Privacy Policy.
Agreement
I, the undersigned, declare that to the best of my knowledge, the information provided and statements made in this application
(pages 1-6 inclusive) and in any attached documents are true. I agree to abide by the Bylaws of the NHPC, as amended or
replaced from time to time, and have read and agree to comply with the NHPC Code of Ethics. I realize that I may lose my
membership and membership privileges if complaints about my practice are found to be in violation of the Code of Ethics, or not
in the best interest of the public.
Signature
Date (MM/DD/YYYY)
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: [email protected]
Page 2
of 6
Liability Insurance Program Application
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Applicant Contact Information (required)
First Name
Initial
Last Name
Business Name (if applicable)
Home Address
Incorporated:
Yes
Province
Postal Code
City
Home Telephone
Business Telephone
Email
No
Fax
Business Website
Regulation of Practice (required)
See the Required Documents section at the top of the Membership Upgrade application.
Have you ever been disciplined or expelled from an association or legislated regulatory body?
If "Yes", Name of Association/Regulatory Body
Yes
No
Yes
No
Yes
No
Date of Expulsion (MM/DD/YYYY)
Reason for Expulsion or Disciplinary Action
Prior Insurance (required)
Have you ever incurred any prior liability claims or losses?
If "Yes", briefly summarize the claim or loss
In the past three years, have you had liability insurance cancelled or coverage refused by an insurer?
If "Yes", Explain
With what Insurance Company were you previously insured for liability insurance? (Indicate “N/A” if no previous insurance)
Professional Liability Insurance/Medical Malpractice
Commercial General Liability (CGL)
Insurance Company Name (not the broker)
Insurance Company Name (not the broker)
Policy No.
Policy No.
Expiry Date (MM/DD/YYYY)
Expiry Date (MM/DD/YYYY)
Was this a claims based policy?
Yes
No
Operations (required)
In the normal course of your practice do you do any of the following? (check all that apply)
Insert fluids, chemicals or foreign objects into bodily orifices
Puncture or other otherwise traumatize the dermis
Perform ear candling
Treat and/or have care, custody and control of animals
Use any sun tanning or related equipment, X-rays, infrared ray, diathermy, quartz lamp, teletherapy units, radium or
radioisotopes
Provide any advice relating to the ingestion of products such as herbal products, nutritional supplements, plant medicine or
chemical substances?
Provide lifestyle/attitudinal or general nutritional counseling beyond that associated with a defined discipline, specialty or
technique or training program approved for membership status by the NHPC
Describe yourself as a "naturopath"
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: [email protected]
Page 3
of 6
Liability Insurance Program Application
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
The NHPC Medical Malpractice insurance component under the Liability Insurance program policy excludes the above
practices (those indicated in the Operations section), except as follows:
Insertion of fluids, chemicals or foreign objects into bodily orifices, including colonic irrigations, naturopathy, advice relating to the
ingestion of herbs, nutritional supplements, plant medicine or chemical substances, with the exception of bona fide members of
the NHPC who were practicing and qualified to perform the above modalities and practices on or prior to July 31, 2001, with
credentials acceptable to the NHPC, and who were members insured under policy # MMC9-0001, issued by Scottish & York
Insurance Co., Ltd., under the NHPC Professional Liability Insurance Program in force as of July 31, 2001.
The NHPC carries out detailed credentialing of all practising members. In no event are such modalities and practices covered
under the Medical Malpractice insurance policy if any such modalities and practices falls outside the defined disciplines,
techniques or specialties approved for membership with the NHPC. If you provide any of these excluded services, please
contact the NHPC to discuss these.
Liability Insurance Program Limits
Mandatory
Medical Malpractice Liability – $3,000,000 each Claim (Occurrence based), $5,000,000 Annual Aggregate;
Legal Expense - $25,000 each Claim, $50,000 Annual Aggregate (applicable to members subject to professional disciplinary
legislation: ON, BC and NL only).
Pays for claims against the member alleging negligence in the treatment of a patient as a result of the member’s bodywork,
resulting in bodily injury, sickness or disease.
Optional
Commercial General Liability (CGL) – $3,000,000 each Occurrence, $5,000,000 Annual Aggregate.
Pays for claims against the member alleging negligence in the operation of the business, causing bodily injury or property
damage, including slips and falls, damage to rented or adjacent premises, and injury from products sold.
Note: This policy excludes claims arising out of any service, treatment, advice or instruction for the purpose of appearance or
skin enhancement, hair removal or replacement or personal grooming.
Premium Calculations
All new members’ first year premiums are prorated to one of two common NHPC membership renewal dates: November 1 or
May 1 to coincide with their membership expiry, with premium adjustments based on a shorter or longer policy term than one
year. Your insurance premium is included in your membership fee. Please contact the NHPC office for a fee quote.
There is one Master Policy which renews every year on November 1, upon which terms and conditions and pricing for the
program may change.
Insurance Selection (required)
Are you an employee (not a contractor) of a clinic and covered under your employer’s Commercial
General Liability policy?
Yes
No
If you are self-employed, do you already have a Commercial General Liability (Business) policy in force?
Yes
No
If you answered "No" to the above questions, you should select Option 1: Medical Malpractice & Commercial General Liability.
By selecting Option 2: Medical Malpractice ONLY, in the event of a claim other than Medical Malpractice related claims, you will
have no coverage for claims such as those of the type listed under the Commercial General Liability description above.
I have read the above and I am selecting:
Option 1: the Medical Malpractice and CGL Package
Preferred Insurance Coverage Start Date (MM/DD/YYYY)
Option 2: the Medical Malpractice ONLY Package
Note: Your insurance coverage start date cannot be prior to this application and
all required documents being received by the NHPC office.
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: [email protected]
Page 4
of 6
Liability Insurance Program Application
Questions? See the FAQ at nhpcanada.org/en/joinnhpc/
Premium and Tax Breakdown (required)
Select your insurance premium and associated taxes (if applicable for your province of residence) from the table below, based on
your insurance selection (Option 1 or Option 2) and your preferred insurance coverage start date indicated above.
Start
Month
Aug-2014
Option 1 – Medical Malpractice & CGL
Premium
MB Tax
QC Tax
ON Tax
93.00
7.44
8.37
7.44
Option 2 – Medical Malpractice ONLY
Premium
MB Tax
QC Tax
ON Tax
64.00
5.12
5.76
5.12
Expiry
Date
1-May-2015
Sep-2014
84.00
6.72
7.56
6.72
57.00
4.56
5.13
4.56
1-May-2015
Oct-2014
135.00
10.80
12.15
10.80
92.00
7.36
8.28
7.36
1-Nov-2015
Nov-2014
125.00
10.00
11.25
10.00
85.00
6.80
7.65
6.80
1-Nov-2015
Dec-2014
114.00
9.12
10.26
9.12
78.00
6.24
7.02
6.24
1-Nov-2015
Premium Plus Tax (if applicable) Total Amount
$
Note: This is to verify the amount out of your total membership fee that you are paying
for insurance. Contact NHPC for a membership fee quote, which will include insurance.
In accordance with NHPC membership terms and conditions, insurance premiums under this program are considered to be fully
earned and subject to a no refund policy, regardless if insurance is cancelled by member request.
Legal (required)
The undersigned confirms and warrants that the information provided herein and hereafter is complete and accurate. Application
is subject to review and acceptance by the NHPC and the insurer, and the information contained within this application forms part
of the insurance contract. All sections must be completed, and the application signed and dated in order to be accepted. The
undersigned must be a member in good standing of the NHPC to be eligible for this insurance coverage. This application is not a
Binder of Insurance. The effective date of insurance shall be the date upon which the completed and signed application and
payment are received at the NHPC office, subject to the insurer’s acceptance of the application, and shall be indicated on the
Certificate of Insurance provided to the undersigned. Coverage is subject to the terms and conditions of the Master Policy
wordings.
Privacy Notice
Subject to the law and Aon’s privacy policy (available online at “www.aon.ca”), I consent to the collection, use and disclosure of
any personal information required for the purposes of assessing my application, providing me with requested insurance products,
services or information, assessing my ongoing needs and offering products or services to meet those needs, communicating with
me, claims administration, data analysis and to detect and prevent fraud.
Signature
Program Sponsor:
Date (MM/DD/YYYY)
Program Insurer:
Program Administrator:
For NHPC Office Use Only (do not complete)
Checked By
Date (MM/DD/YYYY)
Member Number Assigned
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: [email protected]
Page 5
of 6
Payment for Membership Upgrade
Including Liability Insurance Program
Payment for Membership Upgrade
Please contact the NHPC office for a membership upgrade fee quote.
Phone (Edmonton Area): 780-484-2010
Toll-Free Phone: 1-888-711-7701
Email: [email protected]
Payment Information (required)
Promo Code (if applicable)
Payment Amount
$
Paying By
Money Order
Make cheques payable to Natural Health Practitioners of Canada
Cheque
Certified Cheque
VISA/MasterCard Number
Cardholder Name (Printed)
Credit Card
Expiry Date (MM/YY)
Cardholder Signature
Non-Sufficient Funds
If you pay your member application fee by credit card and payment has been denied, we will contact you regarding alternate
payment options.
If the bank denies your cheque, a $50 processing fee will be assessed. Payment will only be accepted by money order or
certified cheque thereafter.
Refund Policy
The NHPC has a no refund policy. A non-refundable $200.00 (plus tax) processing fee will be charged for any withdrawn or
refused applications once submitted. Once the financial transaction is completed, there will be no reimbursement of fees.
Submit all pages of this application (excluding cover) to Natural Health Practitioners of Canada:
by mail: 6th Floor
Contact Us
10339 124 ST
Phone (Edmonton Area): 780-484-2010
Edmonton, AB T5N 3W1
Toll-Free Phone: 1-888-711-7701
by fax: 780-484-3605
Email: [email protected]
Page 6
of 6
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