ALL QUESTIONS MUST BE ANSWERED COMPLETELY. INDICATE “N/A” IF A QUESTION IS NOT APPLICABLE. IF THE SPACE PROVIDED IS INSUFFICIENT TO ANSWER A QUESTION FULLY, PLEASE ATTACH A SEPARATE SHEET. APPLICANT NAME: ______________________________________________________________________ CTCMPAO #: __________________ MAILING ADDRESS: ______________________________________________________________________________________________________ CITY: ________________________________________________ PROVINCE: __________________ POSTAL CODE: __________________ PHONE: _________________________ CELL: _________________________ EMAIL: ____________________________________________ Professional Services Covered Our policy includes the following automatically: ACUPUNCTURE Acupressure Chinese Medicine Counseling (including dispensing of herbs or herbs granule as prescribed by the named insured) Bone Therapy/Topical Application of Chinese Herbs Cupping Gua Sha (Skin Scraping) Heat Treatment Herbology Laser Acupuncture Moxibustion Qi-Gong Tai Chi Tuina

Please list any other modalities, services or techniques that you provide:

Exclusions: (a) Needle Acupuncture unless performed with single-use disposable needles. (b) AIDS and Hepatitis B. (c) Medical doctor, Dr. of Naturopathy, Dr. of Homeopathy, Dr. of Chiropractic and various other exclusions as defined by the policy.

Are you an active member, in good standing with the CTCMPAO? Yes ____ No ____ OR Have you applied, or are you applying, to be a member with the CTCMPAO? Yes ____ No ____

Please provide a description of any products manufactured, distributed or sold. If none, please write “N/A”.

Do you provide services outside of Canada? Yes ____ No ____ IF YOU CURRENTLY HAVE PROFESSIONAL LIABILITY INSURANCE, YOU MUST PROVIDE US WITH THE FOLLOWING INFORMATION. IF YOU DO NOT CURRENTLY HAVE A POLICY, PLEASE WRITE “NONE”. Insurance Company Policy Coverage Limit Policy Expiry Date Retroactive Date Office Use Only.

1. Has insurance ever been declined, cancelled or renewal thereof been refused by an Insurer? Yes ____ No ____ 2. Have you had any losses in the past three years? Yes ____ No ____ 3. Do you have knowledge of any circumstance which could result in a claim or lawsuit being brought against you? Yes ____ No ____

IF YOU ANSWERED YES TO ANY OF THE ABOVE 3 QUESTIONS, PLEASE PROVIDE FULL DETAILS ON A SEPARATE SHEET AND ATTACH IT TO THIS APPLICATION. WITHOUT LIMITATION OF ANY REMEDY AVAILABLE TO THE INSURER, IT IS HEREBY AGREED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM IS EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.

EFFECTIVE DATE OF COVERAGE Coverage will be effective one business day after we receive and approve your application. If you wish to have a specific date in the future, please indicate here.

PROFESSIONAL LIABILITY (PL) only provides coverage for injury you cause to third parties (patients) as a result of your actions as an Acupuncture / TCM Practitioner (injury from a needle or allergic reaction to an herb etc). It does not provide any CGL coverages. COMMERCIAL GENERAL LIABILITY (CGL) only provides coverages for bodily injury or property damage you cause to third parties (customers) as defined by the policy. Bodily injury could include someone slipping on the floor or selling someone a bad batch of herbs. Property damage can include water damage from a tap you left on. It does not provide any Professional Liability (PL) coverages. Both the PL and CGL provide coverage for only you. If any of the following applies to you, please contact our office at 1-800-265-2625 ext 322 or email us at info@acupuntureinsurance.ca • If you have a clinic with other employees, practitioners or tenants • If you have an herb store, or a wholesale or retail of herbs or drugs • If you have a composite medical center PLEASE CHECK ONE. ____ I am a sole practitioner and do not have any employees or any individuals working with me. OR ____ I have employees, practitioners, tenants working for with/for me or I have a herb store or wholesale or retail of herbs or drugs or as a composite medical center. A) TCM herb or herb granule sales for the last 12 months $ ____________ B) Professional or consulting fees for the last 12 months $ ____________ C) Retail sales for the last 12 months $ ____________ Total sales for the last 12 months A+B+C $ ____________ Please provide a list of products sold in line “C” above:

NOTICE CONCERNING PERSONAL INFORMATION I hereby consent to Lackner McLennan Insurance to collect, use and disclose personal information required for the purposes of considering my application for insurance for new or renewal insurance coverage. The Broker is authorized to collect, use and disclose personal information and provide such personal information to third parties, as required, including insurance companies. The Broker may also be required to disclose such personal information pursuant to relevant privacy laws or other laws.

WARRANTY STATEMENT By submitting this Application, you attest that the application has been completed accurately and honestly. No disciplinary action has been or is pending against you. You have never been the subject of any investigation, either civil or criminal, in connection with any sexual act, conduct, molestation and/or assault. You understand that your insurance certificate will provide evidence that you have been added as an individual participant with respect to the coverage and limits of the Master Policy. You understand that the coverage provided by your insurance certificate is subject to all the terms, conditions and exclusions contained in the Master Policy. You further understand that the Insurance Company will rely on the information you have provided in the Application. Failure to pay required premiums and/or false statements on this Application or subsequent renewals shall void this Application and render your insurance coverage null and void and you may be subject to further legal action for making false statements. Signature X ________________________________________________________ Date X _________________________________________

COVERAGE LIMITS PROFESSIONAL LIABILITY (PL) CLAIMS MADE FORM

$1,000,000 each claim & $5,000,000 aggregate or $2,000,000 each claim & $5,000,000 aggregate NO DEDUCTIBLE

LEGAL EXPENSE FOR ABUSE** $100,000 NO DEDUCTIBLE

CRIMINAL EXPENSE COVERAGE INCLUDED** $10,000 limit and aggregate NO DEDUCTIBLE

COMMERCIAL GENERAL LIABILITY (CGL) OCCURRENCE FORM

$1,000,000 each claim & $5,000,000 aggregate or $2,000,000 each claim & $5,000,000 aggregate $1,000 DEDUCTIBLE

TENANTS LEGAL LIABILITY $500,000 NO DEDUCTIBLE

**ABUSE CAN BE SEXUAL, PHYSICAL OR VERBAL ABUSE. THIS COVERAGE WILL REIMBURSE YOU FOR LEGAL EXPENSES IN THE DEFENSE OF ABUSE, PROVIDED YOU ARE PLEADING NOT GUILTY AND FOUND NOT GUILTY. Standard PREMIUM

Premium $1,000,000 Limit – PL ONLY $351.00 Includes 8% PST and 25% commission

$2,000,000 Limit – PL ONLY $496.80 Includes 8% PST and 25% commission

$1,000,000 Limit – PL & CGL $459.00 Includes 8% PST and 25% commission

$2,000,000 Limit – PL & CGL $648.00 Includes 8% PST and 25% commission

PREMIUM CALCULATION 1. Premium Limit from above $ ** Optional ** If you wish to pay by credit card, please add a $16.20 processing fee $ TOTAL PREMIUM PAYABLE $ THIS POLICY REQUIRES THE USE OF STERILIZED/DISPOSABLE NEEDLES AND LIMITS THE SALE OF HERBS TO LESS THAN 15% OF BUSINESS REVENUE. THIS IS ONLY AN APPLICATION AND DOES NOT BIND THE INSURANCE COMPANY. YOU MUST REFER TO THE POLICY FOR COMPLETE TERMS AND CONDITIONS.

CREDIT CARD PAYMENT – If you wish to pay by VISA OR MASTER CARD, please provide information below: Credit Card # Expiry Date

Signature of Cardholder

Have you included:

1. Your signed application2. Your certificate(s)3. Your payment

Thank you again for choosing Lackner McLennan Insurance.