For assistance in filling out this application call: CDSPI Advisory Services Inc. 1.800.561.9401, E-mail: insurance@cdspi.com

* Eligible applicants must be:

• A full-time student enrolled in an accredited undergraduate dental program at a Canadian university; and
• Participating in a university-approved clinical program or placement; and
• Completing training under the direct supervision of a dentist who is licensed to practice dentistry in at least one Canadian province or territory other than Ontario, Quebec or Alberta.

Section 1:   Applicant Information and Party To Be Insured

Section 1 continued:  Applicant Information for {name}

Section 1 continued:  Applicant Information for {name}

Section 2:   Coverage Details

1.     A. Amount of insurance applied for: $3,000,000

B. Deductible: N/A

Coverage Notes: Coverage begins only upon policy approval and issuance is subject to the terms and conditions of the policy.

2. Student Eligibility
(Please read and confirm eligibility by checking the box below):

I confirm that I meet the following eligibility requirements for this coverage:

• I am a full-time student enrolled in an accredited undergraduate dental program at a Canadian university
• I will be participating in a program sanctioned by the university
• I will be practicing under the supervision of a dentist licensed in the province or territory where the program is undertaken

Section 2 continued:   Coverage Details

Section 2 continued:   Coverage Details

4. Coverage Period:

Important Note: Coverage cannot begin earlier than the date the application is received and approved. If a requested start date precedes approval, coverage will commence on the approval/issuance date.

Section 3:   To Be Read, Signed and Dated by the Person To Be Insured

Malpractice Information: I agree that information on claims made against my Malpractice coverage may be disseminated by Zurich Insurance Company Ltd. to CDSPI or CDSPI Advisory Services Inc. (CDSPI’s licensed affiliate), and that such information and confirmation of my insurance coverage status MAY be transmitted to the licensing body of the appropriate province if this information is so requested.

I apply to Zurich Insurance Company Ltd. for the insurance indicated above. The information provided by me is true and complete and Zurich Insurance Company Ltd. may rely on it in issuing insurance coverage to me. I acknowledge receipt of and confirm my agreement with the Privacy Statement. A photocopy or facsimile of this authroization shall be as valid as the original.

I declare that, except as described below, I do not now have knowledge of or information concerning any claim, notice of claim, demand, or suit for professional negligence and there is not any claim or suit pending against me arising out of the performance or non-performance of professional services. I further declare that no claim has been or has to be paid by me or on my behalf and no judgment has been entered against me for damages on account of any malpractice, error, or any alleged malpractice, error, or mistake occurring in the practice of my profession except as follows:

NOTICE ON PRIVACY AND CONFIDENTIALITY
Must be read and retained by the person to be insured

By submitting personal information, including, but not limited to, name, address, date of birth, and medical information, to Zurich Insurance Company Ltd and its affiliates (collectively, “Zurich”) and authorized representatives respecting individuals insured or covered by this policy, you acknowledge and confirm that you have consented to or, if applicable, you have obtained, and are retaining the consent of such individuals to the collection, storage, use and disclosure of their personal information for the purposes of securing and administering such insurance coverage(s Personal information is processed and stored by Zurich and its affiliates and authorized representatives in both domestic and foreign jurisdictions. Please contact the Zurich Privacy Officer if you require further additional information regarding the collection, use, disclosure, processing and storage of your personal information via email at privacy.zurich.canada@ zurich.com or you can review our privacy statement at https://www.zurichcanada.com/en-ca/about-zurich/privacy-statement. The policyholder may refuse to consent or withdraw their consent to the collection, storage, use or disclosure of personal information; however, the refusal to provide consent may result in Zurich being unable to offer and administer insurance coverage or prevent Zurich from being able to pay claim benefits. Zurich is committed to protecting the privacy and confidentiality of information provided. Your file is secured in our offices or those of our administrator or agent. You may request to review your personal information and make corrections by writing to: Privacy Officer, Zurich Insurance Company Ltd (Canadian Branch), 100 King Street West, Suite 5500, P.O. Box 290, Toronto, ON M5X 1C9.

CDSPI and CDSPI Advisory Services Inc. collect, use and disclose your personal information on this application for purposes that include: determining your eligibility for our plans; administering and providing insurance and financial services to you; underwriting; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal, regulatory or contractual requirements; marketing and to advise you of other related products and services. We limit access to your personal information in our files to our employees, authorized agents and third-party service providers, and to any other person you authorize or as authorized by law. These people, organizations and service providers may be in countries outside Canada, so your personal information may be subject to the laws of those countries. You may request to review the personal information your file contains and make corrections by sending a written request to: CDSPI, Attn: The Chief Privacy Officer, 2005 Sheppard Ave East, Suite 500, Toronto, ON M2J 5B4. To find out more about our privacy practices, visit www.cdspi.com/privacy.

Malpractice Insurance is underwritten by Zurich Insurance Company Ltd (Canadian Branch).

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