Applicant Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

Province *

Alberta

Other Other

Postal Code *

Phone Number *

Email Address: *

Confirm email address: *

Do you currently have a CAA practice permit? *

Yes

No

Practice Permit Number: *

No Practice Permit: * 🛈

Student

New Applicant

Retroactive Date:
This is the date you first purchased insurance coverage, if this is your first medical malpractice policy please enter todays date.
Can be found on your current insurance certificate. * 🛈 +

Is your practice permit currently in good standing with your college(s): *

Yes

No

New Policy Effective Date:

All policies under this program will run from effective date until Dec 31, 2025 * 🛈 +

Do you own or operate your own business? *

Yes

No

What is your legal company name? *

How many employees do you have that offer professional services to patients? (not including yourself) * 🛈