If you are an Alberta LPN registered with the CLPNA looking to purchase Medical Malpractice coverage as per the new CLPNA guidelines effective January 1, 2024, please DO NOT apply via this application and refer to the correspondence received from the CLPNA on Oct 10, 2023.

Please answer all questions. Do not leave any space blank. Indicate “NONE” to questions where there is no exposure.

The following provinces are eligible to get direct coverage through our online program: Alberta, BC, PEI, Manitoba, New Brunswick, Newfoundland, Nova Scotia, Saskatchewan.

If your province is not listed please contact our office directly at lpn@lloydsadd.com or 1.800.665.5243 to get coverage placed.

LPN / Company Information

Website Address (if applicable):

First Name: *

Last Name: *

Company Name (if applicable):

LPN License Number: *

LOCATION OF PREMISES:

If you operate in the province of Alberta and are a member of the CLPNA please DO NOT Purchase coverage on this application and contact us at lpn@lloydsadd.com

Street Address: *

Address Line 2:

City: *

Province * 🛈

If you operate in the province of Alberta and are a member of the CLPNA please DO NOT Purchase coverage on this application and contact us at lpn@lloydsadd.com

Postal Code: *

Phone Number: *

Email Address: *

Number of Years in Operation *

Description of Operations: *

Are you a new client or are your renewing existing coverage? *

New Client

Renewing Coverage

Policy Effective Date: (YYYY-MM-DD)

All policies under this program will run from effective date until Jan 1, 2024 * 🛈 +

Estimated Gross Revenue for the next twelve (12) or next fiscal year ($CDN): (Leave Revenue at "0" for USA and Other if you do not operate outside of Canada)

Canada *

USA *

Other *