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
Do you have a Professional Corporation to add?
Please provide your Corporation name:
Practice Permit Number:
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
Prince Edward Island
North West Territories
State or Region
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