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Excess Professional Liability Coverage Application
Please complete this application in full, since it forms the basis upon which insurance is provided.
In the event of a non-disclosure and/or misrepresentation, the policy may be voided at the option of the Insurer.
Primary Contact Details
First Name
*
Last Name
*
Do you have a Professional Corporation to add?
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Yes
No
Please provide your Corporation name:
*
Practice Permit Number:
*
Email Address
Note: Please advise us immediately if your email address changes; otherwise you may not receive critical renewal correspondence
*
Re-enter your email address
*
Mailing Street Address
*
Mailing Address City
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Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
North West Territories
Nunavut
Yukon
Outside Canada
State or Region
*
Country
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Mailing Address Postal or ZIP Code
*
Are you purchasing new excess coverage for the first time or renewing existing coverage?
*
I'm a new applicant
Renewing existing coverage
Lloyd Sadd Insurance Brokers Ltd.
Suite 700, 10240 124 Street
Edmonton, AB T5N 3W6