HPG Insurance P rogramApp l i ca t ion (11 07 16 ) Page1of4

PROLINK|480UniversityAve.Suite800TorontoON.M5G1V2|TF:18006636828|F:4165951649|E:HPG@PROLINK.insure

APPLICATIONFORHEALTHCAREPRACTIONERGROUPINSURANCEPROGRAMSECTION1: APPLICANT INFORMATION1. NameofApplicant:

MailingAddress: City: Province: PostalCode: PhoneRes.: PhoneBus.: Fax: Email: Website:

2. Isyourbusiness: ¨ SoleProprietorship¨ Partnership¨ IncorporatedCompany

If“IncorporatedCompany”pleaseprovidetheincorporatedname:

3. Doyouhaveanyemployees? ¨ YES ¨ NO

If“YES”,pleasecomplete“AppendixA”andwewillprovideyouwithaquote.Additionalpremiumwillapply.

SECTION2: UNDERWRITING INFORMATION

4. Pleasediscloseallprofessionalservicesinwhichyouarepresentlyactivelyparticipating:(Checkallthatapplyorspecifybelow)

¨ Acupressure ¨ Aromatherapy ¨ BodyTalk ¨ BowenTechnique ¨ Craniosacral

¨ Doula ¨ Hellerwork¨ IndianHeadMassage ¨ IonFootMassage ¨ Iridology

¨ LactationConsultant ¨ QiGong ¨ Reiki ¨Reflexology ¨ RejuvenatingFaceMassage

¨ Relaxation/ChairMassage

¨ Shiatsu ¨ SwedishMassage ¨ ThaiMassage ¨ TherapeuticTouch

¨ TouchforHealth ¨ PersonalSupportWorker¨ Other

5. Inthepast,hastheApplicantoranyofhis/heremployeeseverbeenthe ¨ YES ¨ NO recipientofanyallegationsofprofessionalnegligenceinwritingorverbally?

6. Hasanyinsurereverdeclined,cancelledorimposedspecialconditions ¨ YES ¨ NO foranycoverage,foryouoryourentityinthepast?

7. IstheApplicantoranyofhis/heremployeesawareofanyfacts,circumstances, ¨ YES ¨ NO orsituationswhichmayreasonablygiverisetoaclaim,otherthanadvisedabove?

If“YES”toanyofquestions5–7,pleaseprovidefulldetailsonaseparatesheetandattachtoyourapplication.

HPG Insurance P rogramApp l i ca t ion (11 07 16 ) Page2of4

PROLINK|480UniversityAve.Suite800TorontoON.M5G1V2|TF:18006636828|F:4165951649|E:HPG@PROLINK.insure

Coverage Limits&Deductibles Rates Totals

LiabilityCoverage

ProfessionalLiability$2,000,000 EachClaimLimit$6,000,000 AggregateLimitNIL Deductible

INCLUDED $185.00*

CommercialGeneralLiability

$2,000,000 EachOccurrenceLimit$6,000,000 AggregateLimit$2,000,000 PersonalInjuryLimit$5,000 MedicalExpenseanyoneperson$25,000 MedicalExpenseanyoneclaim$500,000 TenantsLegalLiability$1,000Deductible

Pleasecompletethefollowingtable:

LimitsofLiability Premium

BasicPackageupto5Modalities: N/A $185.00

NumberofAdditionalModalities(Ifmorethan5): _____X$25.00 $_________________

TotalPremium: $_________________

MembersJoiningBetween: PercentageofPremium: TotalPremiumDue:

November1st,2016-January31st2017: 100%

February1st,2017–April30th,2017: 75%

May1st,2017-July31st,2017 50%

August1st,2017–October31st,2017: 25%

Sub-Total: $_________________

PST(8%forOntarioResidents)or

RST(8%forManitobaResidents)orQST(9%forQuebecResidents)or

PST(15%forNewfoundlandResidents):

$_________________

NonRefundablePolicyFee:$50.00TotalAmountDue: $_________________

ALLPREMIUMSARESUBJECTTOAPPLICABLEPROVINCIALSALESTAXANDAREFULLYRETAINED.

SECTION3: SELECT YOURCOVERAGE

SECTION4: PAYMENT INFORMATION

HPG Insurance P rogramApp l i ca t ion (11 07 16 ) Page3of4

PROLINK|480UniversityAve.Suite800TorontoON.M5G1V2|TF:18006636828|F:4165951649|E:HPG@PROLINK.insure

P A YMEN T O P T I ON S :

1. Yourpaymentwillbeprocessedonthedatewereceivedyourformunlessyouspecifyalaterdate.

2. Paymentcanbemadebycheque,moneyorder,VISAorMASTERCARD.

3. Makeyourcheque/moneyorderpayabletoLMSPROLINKLtdandmailto: LMSPROLINKLtd. 480UniversityAvenue,Suite800

Toronto,ON.M5G1V2

4. Ifyouopttousecreditcard,completetheattachedCreditCardAuthorizationForm(Page4).

5. Theamountchargedtoyourcardwillbethe“TOTALAMOUNTPAYABLE”.

COVERAGEIS NOTBOUNDUNTIL YOURPAYMENTIS APPROVED I M POR T AN T NO T I C E T O A P P L I C AN T :

ImportantNotice:

A. Coverage cannot be bound unless this application form has been fully completed. The undersigned has the power to complete and execute thisApplicationForm,onbehalfofallpersonsproposedforthisinsuranceanddeclaresthat,afterinquiry,thestatementssetforthherein,togetherwithallmaterialsandinformationsubmittedorrequestedbytheInsurer,istrue.

B. AlthoughthesigningofthisApplicationFormdoesnotbindtheundersignednortheInsurertoeffectinsurance,itisagreedthatthisApplicationFormanditsattachmentsshallbethebasisofthecontractshouldapolicybeissuedandshallbedeemedtobeattachedtoandformpartofthepolicy.TheInsureris hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. If the information in thisApplicationFormmateriallychangespriortotheEffectiveDateofthispolicy,theInsuredwillimmediatelynotifytheInsurerinwritingandtheInsurermayeffectchangesin,orwithdraw,thequotation.

C. It is understood and agreed that if knowledge of any such facts, circumstances or situations exists, whether or not disclosed, any claim or actionsubsequentlyarisingordevelopingtherefromshallbeexcludedfromcoverage.

DisclosureandConsent:As part ofmy application for insurance I consent to the collection and use of personal information required for the purposes of consideringmy application forinsurancebytheinsurerandtheauthorizedinsurancebroker,LMSPROLINKLtd., amemberofThePROLINKInsuranceGroupInc.Theinsurerandthebrokerareauthorizedtocollect,use,anddisclosepersonalinformationandprovidesuchpersonalinformationtothirdparties,asrequiredforthepurposeofunderwritingthisapplicationfor insurance,aspermittedbytherelevantprovincialandfederalprivacy lawsorotherapplicable laws,andasrequiredbytheapplicant’sassociationand/orgoverningbody.IunderstandthatatanytimeImayasktoreviewthepersonalinformationpertainingtomyapplicationforinsuranceandtheinsurerandbrokerwillbeobligatedtoprovidemewithanyinformationIamentitledtoreceiveundertherelevantprovincialandfederalprivacylawsorotherapplicablelaws.IhavereviewedtheinformationinthisApplication,gatheredinformationfromallpartners/directors/officers/employees/agentsunderthisentitywhetherpresentorpriorregardingtheirknowledgeorawarenessofanyclaimsorsituationswhichmaygiverisetoanyclaims.TheClaimInformationForms,ifany,thatareattachedtothisApplicationincludethedetailsof:

A. Allfacts,situations,andincidentswhichhaveoccurredinthepastandwhichmayreasonablybeexpectedtoresultinaclaim,suitorarbitrationagainstus(theApplicant);

B. Allfacts,situations,andincidentswhichhaveoccurredinthepastandwhichmayreasonablybeexpectedtoresultinaclaim,suitorarbitrationagainstus(theapplicant) inthefuture.Allsuchclaims,suitsandincidentshavebeenreportedtoour(Applicants)currentorprior insurer(s). It isunderstoodandagreedthatallsuchclaims,suits,arbitrations,factsituationsandincidentswillbeexcludedfromcoverageunderanypolicyissuedbytheinsurer.

Itisunderstoodandagreedthatfailuretoprovidetrueandcompleteresponsetoanyofthequestions,statementsorrequestforinformationinthisApplicationortoprovideanyotherinformationmaterialtothisApplicationmay,atthesoleoptionoftheinsurer,resultinthevoidingoftheinsurancepolicyissuedinrelianceonthisApplicationand/ordenialofcoverageforspecificclaimsassertedagainstus(theApplicant)oranyotherinsuredunderthepolicy.TheundersignedonbehalfoftheApplicantandallotherinsuredsunderthispolicyissuedbytheinsurer,herebywaivesanydefensetoanactionbytheinsurerforvoidingorrevokingofthepolicybaseduponmisrepresentationoffactorfailuretodisclosematerialinformationinconnectionwiththisApplication.TheApplicantagreestoholdtheinsurerharmlessfrom all loss as a result of any suchmisrepresentation or failure to disclose, including,without limitation, all costs and attorney fees incurred by the insurer inconnectionwithsaidactionforvoidingorrevokingthepolicy.IHEREBYDECLAREthattheabovestatementsandparticularsaretruetothebestofmyknowledge,thatIhavenotsuppressedormisstatedanyfactsandIagreethatthis application shall form part of the insurance policy. I also acknowledge that I am obligated to report any changes that could affect the disclosures in thisapplicationthatoccurafterthedateofsignature,butpriortotheeffectivedateofcoverage.

Applicant’sSignature:_______________________Name(pleaseprint):___________________________Date:__________________

PLEASECOMPLETEANDRETURNTHEAPPLICATIONANDPAYMENTBYONEOFTHEFOLLOWINGMETHODS:

ü V ia EMAIL p lease send to : HPG@LMS.ca ü V ia FAX p lease send to : 416 595 1649 a t tn . HPG PROGRAMMANAGER ü V ia MAIL p lease send to : LMS PROL INK L td . 480 Un ivers i ty Ave . Su i te 800 Toronto , ON. M5G1V2

HPG Insurance P rogramApp l i ca t ion (11 07 16 ) Page4of4

PROLINK|480UniversityAve.Suite800TorontoON.M5G1V2|TF:18006636828|F:4165951649|E:HPG@PROLINK.insure

CREDIT CARD PAYMENT AUTHORIZATION FORM

PLEASE NOTE: FULL PAYMENT WILL BE APPLIED TO THE CREDIT CARD INFORMATION SUBMITTED. ADDITIONAL FEES: Please note that a $35 fee will be assessed for all declined credit card due to funds not

authorized/available or invalid card numbers. Client Name or Entity Name:

Name on Card:

I hereby authorize LMS PROLINK Ltd. to charge the following credit card. ¨ Yes ¨ No

Name of Person Authorizing Payment:

Type of Card: ¨ VISA ¨ MASTERCARD

Credit Card Number:

Credit Card Expiry Date:

Total Amount to be Charged:

Date credit card is to be charged: ____________________________ (if no date provided charges will be processed immediately)

Email address if receipt is required: ____________________________________________ (if no email address is provided receipts will not be provided)

THE FOLLOWING WILL BE COMPLETED BY LMS STAFF:

Customer Code:

Name of LMS Staff _____________________________________________________________________